111‘: 1'13 111 M; {3:32. 1.....‘1"_;'_ 1‘: $2.???

L" 31.. 1. "11-14": 1 \..

‘1. 1 "31“.? '44.;4'Fl'" 4.73.3.3: 1R1. €24..é,41'§.£‘ .3‘En 6:44, E?"13.Ex}l“ ‘1 ”313.1

"' 4' ' “44%" '11:" 13‘ '11. ficfilfitfi‘ 1‘1111' “'31... ”"341:

.'."".j1'.'1"'1..‘1§2:'1.1'311i.¢1' 1'Qg‘11'31'nfifigi‘d1m‘. 1%.... 3:31.. ‘1‘.

"'3'" .42" ""‘1‘ 1. 1'1"}: ”1234'; 1~;fi"lfia.'?z€"" "Hc‘i'f‘l #5::1.

111: 11‘11. 111'“... ‘1...; 1.1“3‘1

1'13' '44? 1:.1'1'1 1,1:1'1‘1" "'“":11..'"3"'3L'£ r. "R
h"'""""""'y"""1"&m;§

‘. )1": 4"!"
"':.1.1.11,.1 4.4.4

|" ’I’L
14.4" [.441'74 ' “:4 14:...
.4

 
 
  

    
     
         

 
 
    
 

H'h'l",
'~'14'_ " 5 :5

  
 
  
   
 
   

3.31%” {51412-4 \2-1 'Fé‘fl
‘ mefig’sfi‘ l ‘ \2 : {'A‘;::“;§~N
'1'" "'"L 41111311531." ' t

. ""'l:: '1'3144131 5% . .

' 4'3... .v‘h 1 1”"“11‘1'1'4: v 3‘1. x.‘ 1. m1: .1» ~

.VHNE}..14'.IR§.(& 4'41 Ru" Wé$fifi #334" $3.51: 9.3.x? '34?" Z .
'51“ ‘41:},

 
 
 
  

211.1
1

'.." “1. '
2......
' 31:1

 
 
  
      
  

 

15:1... . “2'11" 1

        
   
  
     

 

   
 

 
     
    

   
  

 
 
  
 

                
       

    
  
         
  

         
  
  
  
  
   
  
    

    

 

  

 
      

    
  

     
  

       
       
     

   
   

    

   
  
  

  
    
    
  

      

  

    
 
    
  
 
 
 
   

       
     
  

 
  
   
  

."1'1"1':
‘2 W1. 1'11 ' 11 "1' $11.11.“. .1~'.,&.1111.
31. 444.144 111.1": .1... 144.14....11.11'.g.1. .%,.11.... .11. "11.3% thfia‘fibfi‘fifii ‘4.“
' 4 "'6 '1'" 1.11 H"; ' “'12:?! "‘ ‘ ' {Mt
'1 .7 '447'IV'14'4'1411'1'" .. ‘1"41'1 '9'42"§§4“4‘1"'"1" " 41.11 4414' "'2'." '1' “'1'" ['11- 1-1:: ’i‘ig'"1'""§""
"“1'115114 4'1" 11111;" 1 ‘ ":31: 21"" 3.1"." 1" ,1“. 1:41'1'11g1.1'1111 11.11111 11% ‘11 3121‘: “1" ft...»
' 11' 1 ' " ‘3'-‘11 . ‘ - - . -. ... =‘t...1‘:‘~:: ' “
1‘" "11:. .111 . 1211.11 .11 . 1112111111111 :11 ‘1‘ 1 111' 2111:}!
'41 . “'4‘ 1‘. "MW: 1'44 M. . 111414. '11 1.1 *1‘11‘11 .1'
1111 111 11111 ‘1 1o11111"1‘ 1"“111'1‘1: 114': «‘1 111"
1:; .' PV" '111‘1. 4,” '1 1- 5'. {9 1‘ 4... . .31. .
111. 1.11 1. 111 1.41. '1‘11....1..11'13 1111" 1. .34. 1.....1..1..?1fi¢
" " " 2'" ‘ '1'1"""'" 4!""""' h ' '41.": '3'" "4 4"” ""1"~"'2’17'.""{1 m "' 31:42.: 23:“;
' n3 ' '41'42'4'"'44“'"""1""'1¢""" 4' 1 ""'4" "1 ""'11"'4'"""2'<'1. "" '11'1'14‘4' ‘1'”1" '1‘I'E'kfls'd1va‘3'k
1E: 0'44 .14.;14...)1i4111.~'4§14..1.: 11].: 3:144. '1“.:*: .. .31.}...43415“ 441...?“ 41414441.. . .1 '1“... F"1‘.§"'1"1."‘1'1"b2‘" 1"" 4"2i'-1~2‘"'4Z'13"'1'1'E'*'31 .
' . ’45 "' 1" ‘~ 4.. la 41.4, 1:1 "7 _'1‘1;4"44fi"17.;"y ‘v- 1 1'1:- V42 41.1,". "i'f
' "' "4" " ' ' """'"'"" '1' ""4 1"" '11“ “ 11.1... ‘11... 31115131:- ‘1111‘1‘151‘1‘1‘1 1151:3552 w
44"." 11.41.14.411 1.41.42.44.11‘1111411..1 11141.1‘1.114.411.292341111'W'Q51«5.1111'Zfi‘4"““53"“ ”‘15.“
.191 .11 1‘ 1'44 12111111111 “'11111. .‘4‘1.111‘111‘ 12‘1'1‘1 121.1151:
111;... .1111: 1 11111414111. 1.1.1.111 1111131 '1'11'5111 111.11.... 1 1
: ;. 1441.211. . ‘1': , 141. 1.' "1' 111.1"n "12"' “4:444:1'3'43'9'13'3'4' 141.“?3 '1'3‘1" w...
‘ .m’ .:_\“, .. .. 4141.. ~-
1... 1 1 . t. .. 41.11 11., .
j .43.;

-Viw.‘<p
“X.
?'.§.—.>._

2‘ J-"-—v44

m"?
. gnu—sane
__ '13:: ‘

 
   
       

“i“ 3- 2E5
ray: .; '

xi:
1:.

   
  
         
  
   

2.
Ar“ 7% ’ ‘ ‘ ‘i ?r ‘

w tarp?“ =5 .. .2 W
J51:v55r'§-3t'r‘ 22;; f‘ ..- ' ‘ .r

2-.
45‘ -

gr
3

£3;

 
  
 
    

  
  

1:33:3-
'=a’ ‘ A"
3;.

‘ 55%

.13

      
      
   
     
    
    
    

.3

     
      

 

7;.
1t
1 fl?" ' r_ I

 

1.."2‘} 2.1"”? {1%

ha :1 u ”if" iii; 25“

4'3.

1.44'1‘1‘11'91'2'? 1 “H.152- 141;" 3.54%

$41 5 1: .44" 111111. 531......“
11‘

:11.

3.1

.1-1

  

5)..“ - 1". "' ‘ "it: . , A . ’
g A I

I .
fix
-.;. - ӣ2:
V»P£?§E%1

  
  
     

 
 

     
  
 
 
   
       

  
    
  

   

wa

  

 

1-;
. 7.3.7,. _~

5.. . 3:211
“29 Z ‘ .
.rcu 1.

    
      
   
 

   
   
 

.7-2. ..
‘ t

 

  
     
  

  

   
     
  
 
 
 

a. 2.5 «Ha- 2’ ‘

         

   

       
       
  

   

    
   

 

         
   

  

      
 
 

 

 

' "41'1": A.'«‘ ..
' '4 , 11:121.
1' .‘ i1: 1
‘3 '5 4' 1'?
2 u. -. 1’
1-511; ‘
tr , 'A'IJ'J m1 ,1 ; .‘ .
h L; *1. . _
. 1"; H31: '4 ., .
1' 1:11:11" "1'1": {1'4"1 “ 1.1:: . .
" " fi""""' "" ' . 1‘ '1'. .. «11‘2‘2'1 "
i " 44" " ' -,":1.1! ‘1.\' “(Ch'
'1'"""? 14"“? 5- 112‘ '1: .131...
' 1f .41.;1'14 , .143
' '51:"? 1211'“. 1.
. 42 1:}.44 “.1 '. ‘4'.
2-11 .3. .4

«m

- w‘

L I B R A R Y
Michigan Stat:
University

   
 
  

   
 
 

 

This is to certify that the

thesis entitled

THE DIET HISTORY--A TOOL AND A PROCESS: A

SELF-INSTRUCTIONAL MODULE TO FACILITATE

STUDENT DIETITIANS' LEARNING TO ELICIT
A CLIENT'S DIET HISTORY

presented by

Joanne Marie Jasmund

has been accepted towards fulfillment
of the requirements for

 

 

Master' idegreein Nutrition

Major professor

Date August, 1980

 

0-7639

U‘IERJUE’ Finib‘;
25¢ per day per 5:311
ESENENE LIGHT-ii! MLTEnEALS:

Place i3. now; return to remw
mam: from ctrcuuvcn retards

--~—. _.—.—.—-—-u—-

 

 

 

 

 

 

THE DIET HISTORY--A TOOL AND A PROCESS: A
SELF—INSTRUCTIONAL MODULE TO FACILITATE
STUDENT DIETITIANS' LEARNING TO ELICIT

A CLIENT'S DIET HISTORY

BY

Joanne Marie Jasmund

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE
Department of Food Science and Human Nutrition

1980

éfléé‘ ‘75"

ABSTRACT
THE DIET HISTORY--A TOOL AND A PROCESS: A
SELF-INSTRUCTIONAL MODULE TO FACILITATE

STUDENT DIETITIANS' LEARNING TO ELICIT
A CLIENT'S DIET HISTORY

BY

Joanne Marie Jasmund

One component of nutritional assessment, the diet history, is
used to describe a client's dietary status. A survey of the Coordinated
Undergraduate Programs (CUP) in the United States failed to locate an
instructional unit to facilitate student dietitians' learning to elicit
a client's diet history, in accordance with the definition developed by
the investigator. The purpose of the study was to compare the effec—
tiveness of a self-instructional module and a lecture presentation
with the same content, designed according to the Hiob Model.

Summative evaluation was completed with twenty student dieti-
tians enrolled in Michigan State University's (MSU) General Dietetics
Coordinated Study Plan (GDCSP). Student dietitians were randomly
assigned to two treatment groups: ten to receive the lecture pre—
sentation and ten to complete the self—instructional module. The
pre-test and the post-test were identical: the student dietitian,
provided with a simulated client and his/her medical record, was asked
to obtain the client's diet history. An evaluation instrument was

constructed to measure student dietitians' achievement on the tests.

Joanne Marie Jasmund

An Analysis of Covariance was used to determine whether there was a
significant difference in achievement between the effectiveness of
treatment groups in facilitating student dietitians' learning to elicit
a client's diet history. Both lecture and self-instruction were effec-
tive in facilitating student dietitians' learning as determined by gain
in achievement between the pre-test and post-test. The findings failed
to demonstrate a significant difference in achievement between the
treatment groups.

The findings of the study suggest that self-instructional
modules could be used in place of lecture for presenting material

that is relatively stable.

ACKNOWLEDGMENTS

I wish to acknowledge my major professor, Burness Wenberg, for
her enduring support and encouragement in my thesis study. Special
thanks are extended to members of my Graduate Committee, Jenny Bond,
Margo Hodder, and Bruce Miles, whose ideas and guidance facilitated
the development of the self-instructional module.

Special appreciation is given to Frances Price, Mary Jo
Morrissey (Clinical Instructors in the General Dietetics Coordinated
Study Plan), and Polly Junkermier (Assistant Clinical Instructor) whose
contributions were of invaluable assistance in the research. Special
acknowledgment goes to Necia Black, who gave much assistance in
analyzing the data.

Personal thanks go to Clara Steier, a doctoral candidate in
Instructional Development, who provided much optimism and consult in
the development of the self-instructional unit.

To my family and close friends, I am indebted for their
inspiration and moral support in my endeavor.

Sincere thanks is given to the student dietitians enrolled in
Michigan State University's General Dietetics Coordinated Study Plan
whose participation made possible this study.

Acknowledgments would not be complete without recognition to
those who freely gave their time to typing the manuscript: Merri Jo

Bales, Barbara Micetich, Karen Mohler, and Grace Rutherford.

ii

TABLE OF CONTENTS

Page
LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . vi
LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . . . vii
Chapter
I. INTRODUCTION . 1
Definition of Terms . 1
Working Definition of the Diet History . 3
Statement of the Problem . 4
Assumptions 4
Hypotheses . 5
II. REVIEW OF THE LITERATURE . 7
The Diet History . . 7
The Diet History in Nutritional Care . 7
The Diet History and Research Methodology 7
Considerations in collecting food intake data 7
Considerations in determining eating behavior 9
Collection of food intake data . 10
Methodology studies . ll
Implications of the Diet History and the Practice
of Dietetics . . . . . . . 12
Implications of the Diet History and Students
in Dietetics . . . . . . . . . . . . . . . . . . . . 14
Summary . . . . . . . . . . . . . . . . . . . . . 15
Students' Learning . . . . . . . . . . . . 15
Self— Instruction as a Means of Learning . . . . . . . . 16
Summary . . . . . . . . . . . . . . . . . . . . . . . . 17
III. METHODOLOGY . . . . . . . . . . . . . . . . . . . . . . . 19
Needs Assessment . . . . . . . . . . . . . . . . . 19
Defining the Diet History . . . . . . . . . . . . . . 19
Survey of U. 5;. CUP . . . . . . . . . . . . . . . . . 19
Summary . . . . . . . . . . . . . . . . . . . . . . . 20

iii

Chapter

Design of the Study
Research Model .

Development of the Self— Instructional Module .

Development of the Lecture .

Selection of Subjects

Variables .

Testing for Comparison . .
Development of the Self— Instructional Module .

Step 1

Step 2 .

Step 3 . .
Entry test .
Embedded test
Pre- test .
Post- test

Development of the evaluation instrument
Reliability of evaluators
Trial 1
Trial 2
Trial 3
Trial 4
Step 4 .
Step 5 .
Step 6 . . . .
Attitude Survey
Step 7 . . . . .
Development of the Lecture .
Testing of the Comparison

IV. RESULTS AND DISCUSSION .

Results of t- Test . .
Self— Instruction Treatment Group .
Lecture Treatment Group

Results of ANCOVA

Competency Comparison

Curriculum Feedback
Self-Instruction .

Lecture

V. SUMMARY AND CONCLUSIONS

Summary
Conclusions

iv

Page

20
21
21
21
21
23
23
23
24
24
25
27
27
28
29
3O
35
35
37
37
38
39
41
41
42
44
44
46

48

48
49
50
51
54
SS
56
S7

S8

S8
58

Chapter Page

VI. LIMITATIONS AND RECOMMENDATIONS . . . . . . . . . . . . . 60
Limitations . . . . . . . . . . . . . . . . . . . . . . 60
Recommendations . . . . . . . . . . . . . . . . . . . . 61

Instructor's Manual . . . . . . . . . . . . . . . . . 62
Replication of the Study . . . . . . . . . . . . . . . 62
Validity and Reliability . . . . . . . . . . . . . . . 62
Design of the Instructional Unit . . . . . . . . . . . 63
Videotape Accompaniment . . . . . . . . . . . . . . . 64
Design of the Study . . . . . . . . . . . 64
Validation of the Effectiveness of the

Instructional Unit . . . . . . . . . . . . . . . . . 65

Appendix

A. WORKING DEFINITION OF THE DIET HISTORY . . . . . . . . . . 66

B. DIET HISTORY QUESTIONNAIRE . . . . . . . . . . . . . . . . 68
C. REPORT OF SURVEY FINDINGS . . . . . . . . . . . . . . . . 71
D. TESTING PROCEDURES . . . . . . . . . . . . . . . . . . . . 72
E. SIMULATED CLIENT CONSENT FORM . . . . . . . . . . . . . . 84
F. FEEDBACK . . . . . . . . . . . . . . . . . . . . . . . . . 85
G. DIET HISTORY EVALUATION . . . . . . . . . . . . . . . . . 96
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Table

LIST OF TABLES

Results of Pre—Tests and Post-Tests for Process and
Tool Components for Student Dietitians in Self-
Instruction and Lecture Treatment Groups

t-Test Summary Statistics of Pre-Test and Post-Test
Scores for Process and Tool Components for Student
Dietitians in Self-Instruction and Lecture Treatment
Groups

ANCOVA Summary Statistics of Pre-Test and Post—Test
Scores for Process Component for Student Dietitians
in Self-Instruction and Lecture Treatment Groups

ANCOVA Summary Statistics of Pre-Test and Post-Test
Scores for Tool Component for Student Dietitians in
Self-Instruction and Lecture Treatment Groups .

Number of Student Dietitians in Self-Instruction and
Lecture Treatment Groups by Range of Percentage
Achievement on Pre-Test and Post-Test Scores for
Process and Tool Components .

vi

Page

49

50

53

53

55

Figure

1.

F.1

F.2

F.3

LIST OF FIGURES

A Systematic Approach for Module Design: The Hiob
Model . . . . . . . . . . . . . . . . . . . .

Hierarchial Analysis of Learning Outcome for Diet
History Instructional Unit

Rating Procedure for Evaluation of Diet History
Audiotape Interviews

Tabulation of Responses on Attitude Survey

Tabulation of Responses on Curriculum Feedback--
Lecture .

Tabulation of Responses on Curriculum Feedback--
Workbook

vii

Page

22

26

36

88

91

94

CHAPTER I

INTRODUCTION

"The clinical dietitian translates nutritional and behavioral
sciences, and the study of foods, into the skills of nutritional care
of people. . ." (Mason et_al,, 1977). According to Mason et_al,, the
”facilitation of client independence through nutritional counseling"
is the clinical dietitian's primary responsibility. The essentials
of nutritional counseling include assessment, planning, implementation,
and evaluation. Assessment consists of the collection and analysis of
information obtained from the client. The collection of pertinent
dietary, physical, biochemical, and clinical data are included in
the assessment component. The diet history is one of the assessment
tools clinical dietitians use to acquire data for assessing a client's

dietary status.

Definition of Terms

 

The following terms are presented to facilitate reading the

thesis.

Dietary status: A statement of "what an individual has been eating.
It gives no direct implication of nutritional status--only
presumptive evidence if his nutritional requirements are
average and there are no conditioning factors present"
(Young, 1965). ’

Nutritional status: "Refers to the actual nutritional condition of
the patient as measured by physical examination, laboratory

determinations, pathologic morphology and therapeutic response
under controlled conditions. Nutritional status is influenced
not only by dietary intake but also conditioning factors, such
as increases in nutrient requirements, excretions, or destruc-
tion and interferences with nutrient intake, absorption or
utilization which may be operating either currently or in

the past" (Young, 1965).

Patient/alient: The individual receiving the dietitian's services.
These terms are used interchangeably.

Tool: Something used in performing an operation or necessary in the
practice of the dietetic profession.

SelfLinstructional module: "A self-contained learning unit with well-
defined objectives. Usually it consists of learning materials,
a sequence of activities, and provisions for evaluation. Stu-
dents may move independently at own rate and at times of their
own choosing" (Cross, 1976).

Learning outcome: A clear indication of the outcome of the instruction;
what the learner should be able to do after instruction.

Entry test: A test to determine whether learners possess the critical
knowledge, skills, and attitudes prerequisite to success in the
instruction.

Pre-test: A test to determine whether learners already possess the
knowledge, skills, and attitudes taught in the instruction.

Embedded test: A test or practice exercise interspersed throughout the
instruction to provide learners practice and feedback in apply-
ing each new concept or skill taught.

Post-test: A test to measure learners' achievement of the learning
outcome following instruction.

Attitudinal test: A test to solicit learners' attitudes regarding
the instruction.

Criterion referenced test: A test designed to elicit a measurement
that can be interpreted according to a given performance
standard.

Formative evaluation: The process of testing the instruction during
its development in order to obtain information for modification
and improvement purposes.

summative (field) evaluation: The process of testing the instruction
with learners of the target population after formative
evaluation.

Working Definition of the Diet History

 

Throughout the development and formative evaluation of the
instructional units, the working definition was modified and the

following definition evolved.

The diet history represents both a tool and a process used
by clinical dietitians to assess clients' dietary status.

As a tool, the diet history is a retrospective account of a
client's past food intake and eating behavior. The description of the
food intake should provide an estimation of the typical food intake of
an individual (what the client eats). The information obtained should
be both qualitative (nutrient density) and quantitative (amount con-
sumed), if the diet history is to be representative of the client's
food intake. A client's eating behavior is characterized by the
individual's usual pattern of eating, variations of food habits,
and the impact of variables (physiological, psychological, and
environmental) which influence the food chosen for consumption.

As a process, the diet history represents a procedure for
collecting past food intake and eating behavior data. The interview
is a mode by which the collection of meaningful information about the

client is obtained.

The proposed definition of the diet history was agreed to by
the clinical faculty as a working definition and was used for the

present study.

Statement of the Problem

 

The presentation of the diet history concept to student
dietitians enrolled in Michigan State University's (MSU) General
Dietetics Coordinated Study Plan (GDCSP) does not conform to the
preceding definition. The challenge to the investigator was to
identify an instructional method to facilitate student dietitians'
learning to elicit a client's diet history according to the definition.
The investigator approached the problem with the question, "Do any
instructional units applicable to MSU's GDCSP on facilitating student
dietitians' learning the diet history exist according to the defini—
tion?" If the survey identified an instructional unit applicable to
MSU's GDCSP in accordance with the definition, the investigator would
pursue its availability for testing purposes; if none were located,
the investigator would develop one. A survey of the Coordinated
Undergraduate Programs (CUP) in the United States failed to identify
an instructional unit on the diet history in accordance with the
definition. The investigator proceeded to develop an instructional

unit on facilitating student dietitians' learning the diet history.

Assumptions

 

The following assumptions were made in conducting the study.
1. An instructional unit on the diet history according to the
definition does not exist.
2. An instructional unit on facilitating student dietitians'
learning the diet history is likely to be incorporated in
a CUP where didactic and field experience interface, if one

exists.

The student dietitians have received general exposure to the
concept of the diet history but not as specified according to
the given definition.

The simple random sampling technique used to assign the student
dietitians to one of two treatment groups is an appropriate
sampling technique for the proposed study.

The instructor for the IeCture presentation possesses at least
average teaching abilities.

Effectiveness of the lesson can be determined by examining the
treatment method (self-instruction and lecture) as the only

independent variable.

Hypotheses

 

The following hypotheses were addressed in the study to

determine the effectiveness of each treatment method for both the

process and tool components, separately.

1.

MSU student dietitians given a selfLinstructional module

on eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre-test to post-test for the process

component.

MSU student dietitians given a selfLinstructional module

on eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre-test to post-test for the tool component.

MSU student dietitians given a lecture presentation on
eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre-test to post-test for the process component.

MSU student dietitians given a lecture presentation on

eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre-test to post—test for the tool component.

 

Hypotheses 5 and 6 compared the effectiveness between the

lecture and the self-instruction groups, for both the process and

the tool components, separately.

5.

MSU student dietitians given a selfLinstructional module
and MSU student dietitians given a lecture presentation on
eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history, as measured by the identical post-test for the
process component.

MSU student dietitians given a selfLinstructional module
and MSU student dietitians given a lecture presentation on
eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history, as measured by the identical post-test for the
tool component.

CHAPTER II

REVIEW OF THE LITERATURE

The Diet History

 

The Diet History in Nutritional Care

 

Dietitians participate in nutritional assessment in population
surveys and in health care programs (Shapiro, 1979).

The investigator could not locate any reports in the literature
about the diet history in the context of practicing dietitians in a
health care setting with regard to internal or external validity and
reliability.

The Diet History and Research
Methodology

 

Considerations in collecting food intake data. Obtaining

 

complete and accurate food intake data about a client is a complicated
task (Beal, 1967). Lack of agreement regarding "what" and "how" data
should be gathered contributes to the problem of identifying which
clients data should be collected and whose responsibility is the
collection.

The intended use of the food intake data is a major consider-
ation in collecting the data. Assessment of food intake data is pre-
requisite to nutritional care planning and nutritional counseling for

practicing dietitians. In research, the collection of food intake data

often focuses on large groups of individuals (i.e., epidemiologic
or clinical studies) where the mean intake of the group is of value.

Thus, the degree of accuracy required is contingent on the
purpose for collecting the data. Gross distinction in food intake
among a large number of individuals may be permissible. Accuracy is
of greater importance when the information pertains to an individual
client. Estimates of food intakes are more likely to be representative
for groups of people than for individuals (Young et_al,, 1952; Trulson,
1954).

Characteristics of the individual from whom food intake data
are solicited are important in deciding which procedure for obtaining
food intake data is appropriate. The quality of data obtained depends
on the ability of the client as well as motivation to cooperate (Reed
and Burke, 1954; Adelson, 1960; Beal, 1967). Faltering memories impede
the collection of accurate information based on past consumption. One
explanation for the lack of precision obtained by an individual's esti-
mation of past food intake is that s/he does not know exactly what or
how much food is eaten daily (Huenemann and Turner, 1942). Most
individuals are not accustomed to take notice of their food intake.

What information is considered critical for assessing a client's
dietary status? Huenemann and Turner (1942) cite the need to gather
qualitative and quantitative food intake information. Qualitative
food intake data identifies the nutritive quality of foods consumed
with respect to nutrient density. Quantitative food intake data are

measures of the amount of foods consumed. A description of a client's

dietary status is valid only when both qualitative and quantitative
food intake data are considered in the assessment.

Considerations in determining eating behavior. In addition to

 

food intake data, factors which influence the foods chosen for consump-
tion are essential in assessing the client's dietary status. A
client's food intake is affected by fixed and flexible variables.

Fixed variables influencing the client's food intake are those
which the client has little control over or which are not easily manip—
ulated. The client's age, sex, marital status, number of people in the
family, address, birthplace, level of education, occupation, income,
and religion, may have a bearing on what the client eats (Blecha, 1951;
Wilson and Wilson, 1966; Niehoff, 1969; Bartholomew and Poston, 1970;
Huenemann, 1973; Hirsch et 31., 1977). Physical and biological factors
also contribute to the client's food consumption.

Flexible variables are those which the client has some control
over which relate specifically to existing health beliefs and attitudes,
eating patterns, and environmental factors (Gifft, 1972). The client's
perceptions of nutrition and health may have a positive or negative
influence on his/her food selection. Eating patterns established by
the client which affect the kinds and amounts of food consumed include:
time, place, frequency of eating, conditions under which food is con-
sumed, and relationship of food intake to physical activity.

A recognition of these variables and an appreciation of their
significance provides the dietitian a basis for planning a client's

nutritional care or counseling a client.

10

Collection of food intake data. How does the dietitian collect

 

the pertinent data described in the preceding paragraphs? Although
much of the literature describing the collection of food intake data
has focused on dietary methodologies for research, a description of
these methods provides implications for the practicing dietitian in
eliciting meaningful information from clients in a health care setting.

Methods described in the literature examine food intake from
either a historical or from a "here and now" perspective. Becker et_
31, (1960) have conveniently classified the collection of food intake
data into two distinct methods: food record and the dietary history.

A dietary record is a written diary of all foods and beverages
consumed by an individual in a given time period (Trulson and McCann,
1959). Procedures for collecting food intake data by a food record
include weighed, measured, and estimated amounts of food consumed.
Dietary records are used to examine the current food intake of a
client: what the client is eating.

The diet history provides food intake data representing an
individual's past food intake: what the client ate in the immediate
past for a fixed period and what the client's usual food intake was
over a longer period of time (Huenemann and Turner, 1942; Young and
Trulson, 1960; Burke, 1947). The food intake data obtained by a diet
history are based on estimated amounts of food consumed and frequency
of use. Estimates of food intake are subject to errors of observation
and memory as well as to a conscious or an unconscious exaggeration or

minimizing of food intake (Beal, 1967). The food frequency serves to

11

verify the data gathered (Burke, 1947; Blecha, 1951; Reed and Burke,
1954).

Methodology studies. Through a review of the literature, the

 

investigator identified numerous reports on the dietary record. Many
studies have been conducted using the dietary record as the method
employed to assess the food intake of individuals and groups (Sims,
1978; Harper 33.31:: 1978; Grotkowski and Sims, 1978; Kohrs §£.El:»
1978; Bray 33 31:, 1978).

The comparison of the dietary record with other methods of
dietary investigation (recall or dietary history) is a subject of
active interest (Huenemann and Turner, 1942; Bransby et_al,, 1947;
Eads and Meredith, 1948; Ohlson et_a13, 1950; Young et_al,, 1952;
Trulson, 1954; van den Berg and Mayer, 1954; Adelson, 1960; Stefanik
and Trulson, 1962; Bray et_al,, 1978).

Several investigators have studied the dietary record
attempting to eliminate much of the ambiguity associated with the
dietary record method. Studies have focused on: the minimum length
of time required to be representative of an individual's food intake
(Koehne, 1935, Eads and Meredith, 1948; Chalmers et_al,, 1952; Trulson
and McCann, 1959); the determination of day, week, or seasonal effect
for study (Chalmers et_al:, 1952; Trulson, 1955; Leverton and Marsh,
1937); and weighed versus measured food record (Turner, 1940; Huenemann
and Turner, 1942; Bransby et_a13, 1947).

The diet history, its attributes, and its shortcomings in col-

lecting food intake data, have received much study. The diet history

 

12

yields information about the variables affecting an individual's food
intake in addition to food intake data, increasing its value for the
practicing dietitian.

In the 1940's, Burke developed the dietary history as a
research tool. Burke's detailed dietary history is appropriate for
research but has no use to the practicing dietitian. Several investi-
gators have studied the internal validation and reliability of Burke's
dietary history or some modification of it (Turner, 1940; Young et_a1,,
1952; Huenemann and Turner, 1942; Blecha, 1951; Beal, 1967; Bray 33 a1),
1978). Comparison studies conducted by several investigators have
attempted to establish external validity and reliability (Beaudoin
and Mayer, 1953). From the number of investigators, no one clear
determination of the diet history has been derived.

Implications of the Diet History
and the Practice of Dietetics

 

 

Gathering food intake and eating behavior data from a client
is the forerunner to planning and implementing the nutritional care of
clients (Blecha, 1951; Johnson, 1975; Galbraith, 1975; Diet Therapy
Section Committee, 1975). Over thirty years ago Burke (1947) reported
that an "individual's nutritional status can be no better than his past
and present food habits permit." The estimation of a client's dietary
status has long been recognized as a primary function of the dietitian
(Blecha, 1951; Young, 1965; Johnson, 1975). The investigator concurs
with Young and Trulson (1960) who adeptly wrote, "If dietary history
or dietary instruction is worth doing at all, it is worth doing well."

At best, the information obtained is of subjective value (Turner, 1940).

13

In 1976, the Joint Commission on Accreditation for Hospitals

(JCAH) defined standards for dietetic services as follows:

the administration of the nutritional aspects of patient

care shall be under the direction of a qualified dietitian

[whose] duties shall include: recording dietary histories

of patients such as those with food allergies and those

unable to accept a limiting diet regimen.
Compliance with the JCAH standard is impeded by the various interpre-
tations regarding implementation of the standard and definition of the
diet history. Is the dietitian solely responsible for obtaining and
recording the diet history? Can the function of taking a client's diet
history be delegated to dietetic support personnel such as a dietetic
technician under the direction of a qualified dietitian? The feasibil-
ity of delegating simplified procedures and tasks to dietetic support
personnel has been studied by several investigators (Becker et_al,,
1960; Lumsden e: 31., 1976; Shapiro, 1979). Lumsden et_a1, (1976)
reported that 85 percent of the dietitians surveyed were willing to
delegate the task "take accurate and informative dietary history
records" to dietetic technicians.

A survey initiated by a Committee on Nutrition established by
the Medical Society of New Jersey, showed that a minority (20 percent)
of the respondents (dietitians) indicated that the recording of a diet
history was part of their*therapeutic consultations (Jacobson, 1975).
Since the survey question addressed the recording of the diet history,

conclusions cannot be drawn regarding the taking of the diet history

or the recording of the assessment of a diet history.

14

Weed and Molleson (1977) investigated the prevalence of diet
history documentation and reported that 30 percent of the dietitians
studied recorded the diet history on the dietary card; 5 percent of
these diet histories also appeared in the medical record, while another
3 percent of the diet histories were recorded in the medical record but
were not on the dietary card.

Tobias and Van Itallie (1977) reported an evaluation of the
nutritional practices in two teaching hospitals which showed that for
approximately 90 percent of the patients studied, the data in the med-
ical record were suggestive of the need for a diet history. Yet a
diet history obtained by a dietitian was elicited from only 10 percent
of these patients.

These studies illustrate the lack of communication between
dietitians and the medical staff and among dietitians.

Implications of the Diet History
and Students in Dietetics

 

 

There is a growing demand for appreciation of specialized
knowledge and expertise in human nutrition in the clinical setting
(Study Comm., 1972). Forcier EE.§1: (1977) reported the findings of
a study on practicing dietitians' perceived limitations to their
participation in nutritional assessment. Frequently cited limitations
included lack of time, lack of supportive personnel, lack of educational
preparation in general and insufficient opportunities to become skilled
at assessment procedures and too few available tools to facilitate them

in their professional role (Forcier et_al,, 1977). If dietitians' roles

15

include nutritional care planning and nutritional counseling, then
dietitians must become competent in their perceived and ideal roles
(Schiller and Vivian, 1974).

The Study Commission's Report (1972) regarding the quality of
education recognized the need for dietitians to delegate some of their
activities to dietetic support personnel which would provide more
time for dietitians to function at a higher professional level. In
addition, the Study Commission reported the existence of great and
unacceptable variation in the quality of instruction and learning
opportunities. Future student dietitians will benefit as the Study
Commission's findings are reacted to by dietetic educators. Student
dietitians who are adequately trained in the knowledge and skill of
the diet history will be prepared to function at a truly professional

level.

Summary
A review of the literature failed to identify any studies which

described any aspect of student dietitians' learning the diet history.

Students' Learning

 

Though a needs assessment (p. 19) failed to identify any
instructional units facilitating student dietitians' learning to elicit
a client's diet history in accordance with the investigator's defini—
tion, several instructional methods in current use were listed according
to the respondents' perception of the diet history. These instructional

methods include: lecture, simulation, role—playing, supervised field

 

16

experience, workshops, observation, discussion, assigned readings,
audiotape, and videotape. Many of these methods were used in

combination; none exclusively by self-instruction.

Self—Instruction as a Means of Learning

 

Self-instruction has increased in popularity as an effective
instructional method.

Self-instructional materials have been used with success at
Syracuse University in the Department of Nutrition and Food Science
(Short, 1971). The revision of their dietetic curriculum was directed
towards reducing problems associated with teaching nutrition, as well as
making the classes more interesting, exciting, and relevant to the stu—
dents. Short reported that an evaluation of the self-instructional
curriculum indicated that students liked being able to self-pace and
preferred having the responsibility of scheduling. A study of their
curriculum (1969-1970) to determine whether self-instruction was an
effective teaching method for nutrition courses produced favorable
results. The study illustrated a trend towards higher achievement
scores for the self-instructional group. In addition to the cognitive
results, positive affective changes were noted with a decrease in
student anxiety and fatigue and an increase in social affection and
happiness.

Self-instruction facilitates students' educational development
by placing the responsibility for learning on the students. Self-
instruction also increases the efficiency of the instructor. Once

developed, the instructor can assist students who require additional

 

17

help, as well as enrich the learning of students who desire additional
information. Furthermore, self-instruction can be as easily implemented
for 100 students as 10 students. For material which the content is
stable, self-instruction is appropriate.

The Study Commission on Dietetics recommended that various
instructional strategies be explored to improve the quality of the
education of future dietitians (1972). Self-instruction was identified
in the Essentials for Coordinated Program in Dietetics as one strategy
to prepare dietitians (1976).

Many different instructional models exist to design educational
materials. Several have evolved from a basic systematic approach,
characterized by an input-output-feedback-revision cycle (Andrews and
Goodson, 1980). The systems approach is a problem-solving process; it
relates all relevant factors in a given problem systematically. Hiob's
Model is one instructional model which was developed and tested at
Michigan State University (Hiob, 1978) to effectively design self-
instructional modules for the dietetic curriculum (Morrissey, 1976;

Gines, 1978).

Summary
The need for instructional materials to facilitate student
dietitians' learning to elicit a client's diet history is well docu-
mented. A lack of reported research on the diet history in clinical
practice or on students' learning the concept of the diet history

exists. Self—instruction as a teaching strategy seems to be an

18

appropriate method. Through the remainder of the thesis, a study is
described which purports to clarify the concept of the diet history
in clinical practice and to examine the effectiveness of self-

instruction on facilitating students' learning to elicit a client's

diet history.

 

CHAPTER III

METHODOLOGY

Methodology is described under the headings of Needs Assessment,
Design of the Study, Development of the Self-Instructional Module,

Development of the Lecture, and Testing of the Comparison.

Needs Assessment

 

Defining the Diet History

 

The clinical faculty of MSU's GDCSP reached consensus on the
working definition of the diet history written by the investigator.
Additional support of the definition was secured from the Coordinated

Undergraduate Program (CUP) Directors in Michigan (Appendix A).

Survey of U.S. CUP

 

A one-page questionnaire was developed to identify existing
instructional units on the Diet History (Appendix B). A glossary of
terms was enclosed with the questionnaire to clarify any ambiguity
associated with the terminology. The questionnaire was pilot tested
by the CUP directors in Michigan. Suggestions for improvement were
incorporated. The questionnaires were mailed 24 September 1979 to
the sixty-seven CUP directors or program representatives identified
in the 1979 Directory of Dietetic Programs. The survey population was

given a one-month response period to complete and return the

19

 

20

questionnaire. Time constraints precluded a follow-up mailing to gain
additional responses.

Survey responses were accepted through 19 November 1979, at
which time fifty-one (66 percent) of the questionnaires had been
returned. Seven of the respondents indicated that their institution
possessed an instructional unit on the diet history suited to their
curriculum. Of those seven respondents, four indicated an interest
in having their instructional unit reviewed for testing purposes.

None of the instructional modules reviewed were designed according
to the definition. A report of the findings was mailed to the

respondents 21 November 1979 (Appendix C).

Summary

In view of the lack of an existing self-instructional module
on facilitating student dietitians' learning to elicit a client's diet
history, the value of self-instruction as a teaching alternative, the
recommendations of the Study Commission on Dietetics and Essentials
for CUPS, the investigator proceeded to develop and evaluate a self—

instructional module on the diet history.

Design of the Study

 

The design of the study is described under the headings Research
Model, Development of the Self-Instructional Module, Development of the

Lecture, Selection of Subjects, Variables, and Testing for Comparison.

21

Research Model

 

The Hiob Model (1978) was selected for designing the study.
The model consists of six components. Each component describes a set
of procedures which the instructional designer works through to design,
produce, evaluate, and revise an instructional unit (Figure 1).

Development of the Self-Instructional
Module

 

A self-instructional module to facilitate student dietitians'
learning to elicit a client's diet history was developed in print format
according to the Hiob Model. The process of media selection was made

based on criteria presented in the Hiob Model (1978).

Development of the Lecture

 

A lecture was subsequently developed as an oral presentation
to facilitate student dietitians' learning to elicit a client's diet
history using the Hiob Model as the research design. The instructor
for the course in which the testing was conducted, was responsible

for presenting the lecture.

Selection of Subjects

 

The student dietitians enrolled in the first professional year
of MSU's GDCSP were selected to participate in the study. Admission of
students in the GDCSP was by a random number procedure in which one of
the eligibility criteria for selection is a Grade Point Average of 2.75
(GDCSP Admissions Committee, 1978). The twenty student dietitians were

enrolled in HNF 302-Dynamics in Dietetics II. A table of random numbers

22

.ooooz moo: oee

”:wfimoo oaswoz How :omopmm< oflomeoomxm <

 

.H ooswod

 

 

q293mm _
._ T

 

 

 

 

 

 

 

coHomsfim>o
eaofim
machm HHmEm
0:0 oo oco
composfim>o
o>oomEHod

 

 

 

 

 

 

 

 

 

 

 

 

.o:

 

 

 

 

 

 

 

o doom

A doom

oesooooo

omopupmom

noevoch

omoouopm

«meme Ho>oH xuoco
mosgccooo AI! momma AI' moEoooso 3 moeoooso
:ommoH compo>oooe :ofinoomno wcflchmofi Maochmofi
poohomcou :OmmoH smfid mo~o>oo onxamc< xmfloomm

m doom 4 doom m doom N doom o doom

 

 

23

was used to place the student dietitians in the treatment groups:
ten to receive the lecture treatment, and ten to receive the self-

instruction treatment.

Variables

The treatment method (lecture and self—instruction) was the
independent variable for the study. The dependent variables for the
study included the selection of subjects, their educational status,
implementation time of the study, and the pre-test and the post—test

for the study.

Testing for Comparison

 

The study was conducted Winter term 1980 to coincide with the
time at which student dietitians would be studying the diet history.

The student dietitians in both treatment groups received
written and verbal instructions given by the investigator. The pre-
test was administered to the subjects in both treatment groups prior
to instruction, by the investigator. Following the implementation of
the treatment, the investigator administered the post-test to all of

the subjects.

Development of the Self-Instructional Module

 

The self-instructional module was developed following the six
steps of the Hiob Model. A discussion of each step of the Hiob Model
is detailed in two ways. First, the characteristics of a step in the
Model is described. Second, the particulars in applying the step to the

module being developed is illustrated.

 

24

Step 1

Step 1, specify learning outcomes, requires the instructional
designer to identify what the students will be able to do after com-
pleting the lesson. The learning outcome is a concise statement which
includes the performance required by the learner, the conditions under
which the learner is to perform, and the minimum performance level
acceptable. The learning outcome for the self-instructional module
was:

Given a simulated client and his/her medical record,

the student dietitian will be able to elicit the

client's diet history with 86 percent accuracy,

according to the performance criteria.
Eighty-six percent was selected as the competency level. This level
represents performance which the author considers initially satisfactory
for student dietitians. After practice, a higher level of performance
may be expected. Setting the performance level extremely high initially
may discourage students who are unable to achieve the performance
standard. Students' self-confidence may be developed if they are
able to experience success and to receive positive feedback on some

aspect of their first attempts. A performance level below 86 percent

does not ensure that basic concepts and principles were learned.

Step 2

Step 2, analyze the learning outcome, is the instructional
analysis which identifies subordinate knowledge, skills, and attitudes
which are required for the student to successfully meet the learning

outcome. Step 2 is important in identifying all critical content which

25

needs to be included in the lesson. There are several techniques that
can be applied to the instructional analysis. The hierarchial analysis
technique was used to design the self-instructional module in the
present study.

Subordinate skills used in taking a client's diet history were
identified using the hierarchial analysis (Figure 2). The analysis was
initiated by asking "What does the learner have to know or be able to
do so that simply given instruction s/he could perform the learning
outcome?" The question was considered at each subordinate skill of
the hierarchy to ensure that an appropriate and valid hierarchial
analysis of the learning outcome was achieved. The investigator
examined the hierarchy to determine which knowledge and skills the
student should possess prior to the instruction (entry behavior).

The entry knowledge and skills identified are listed in Figure 2.

Step 3

Step 3, develop criterion referenced tests, follows the
instructional analysis. Criterion referenced tests serve two functions:
(1) to evaluate the learners' progress, and (2) to provide the instruc—
tional designer feedback regarding the effectiveness of the lesson.
Criterion referenced tests are developed for each step identified
through the instructional analysis; performance on these test items
is used to assess whether students have achieved the objective of

each subordinate skill in the lesson.

 

 

26

 

SKILL

 

12. Generates data regarding food intake and Learning Outcome
eating behavior simultaneously (Final Skill)

 

_-—---—-----—-------—-—-—----- ----------------------------------------

ll. Identifies eating behavior

10. Generates a food frequency to verify (cross-check)
food intake data collected
9. Generates food intake data

a. Generates usual food intake record
b. Generates 24 hour diet recall

 

 

 
    

8. Chooses data collection method
Subor-

dinate

7. Discriminates content of interchange Skills

6. Discriminates between effective and
ineffective communication skills

5. States the purpose of the diet history
to the client
4. Chooses sources for collecting dietary data

a. Chooses to use the medical record and
health care staff
b. Chooses the client and significant others

3. Identifies the need for a diet history

2. States definition and function of a diet history

b—-------------—------C-------------—----------—-—---———------------------------------ ------———-----

1. Knowledge and Skills

Has a basic knowledge of food, eating behavior and Knowled e
nutrition with their implications for good health and Skifis

Has basic understanding of interpersonal
communication principles

Has general knowledge about interviewing (intro-
duction, preparation of environment, closure)

 

Has limited experience using 24 hour diet recall
and usual food intake record

 

 

Figure 2. Hierarchial Analysis of Learning Outcome for Diet History Instructional Unit.

 

 

 

27

There are four types of criterion referenced tests described
in the Hiob Model. These include:
Entry test: determines whether learners already possess
the knowledge, skills, and attitudes pre-

requisite to success in the instruction.

Pre-test: measures learners' ability to perform the
learning outcome prior to instruction.

Embedded test: provides learners practice in applying
each new concept or skill taught.

Post-test: measures learners' achievement of the
learning outcome following instruction.

Each of these tests are described below in relation to the deve10pment
of the diet history module.

Entry test. The present study did not incorporate an entry

 

test. Prerequisites of the student dietitians were assessed according
to their status in the GDCSP since student dietitians are not permitted
to progress to the next course in the program until competency of the
material prior to the course has been demonstrated.

The remaining three types of tests (pre-test, embedded test,
and post-test) were incorporated in the self-instructional module.
The embedded test is described next, followed by the pre—test and the
post-test which are described together.

Embedded test. Throughout the self-instructional module

 

embedded tests provided the student dietitians practice in applying
each new concept or skill taught. Embedded tests allowed the student
dietitians to self-evaluate using the feedback provided for each
exercise. The feedback informed the student dietitians about their

progress. Student dietitians were instructed not to proceed until a

28

subordinate skill had been mastered. Embedded tests were included in
every section of the self-instructional module for the reasons listed.
An example follows of an embedded test question illustrated in the
module, after a piece of material had been presented.
Concept: Discriminating between effective and
ineffective communication.
Embedded test: Rank the following questions from

best to poorest stated. Write your reason
for the rank given.

 

Rank
1. "You don't drink alcohol do you?"
2. "How much alcohol do you drink?"
3. "Is alcohol a beverage you drink?”
Reason:

 

 

 

The type of questions developed for the self-instructional module
attempted to give student dietitians practice in applying the material
taught and not have them parrot how a particular item is done. In
designing the self-instructional module, three or four test items were
developed for each subordinate skill in the hierarchy.

Pre-test. In the test setting, the pre-test was used to
establish baseline data for measuring differences in learning achieve—
ment between the lecture and the self-instruction treatment groups
(Appendix D). In application, learners who achieve competency on the
pre-test may not be required to complete the module, or the pre-test may
be used to determine which subordinate skills of the module a learner,

having mastered, may omit.

29

Post-test. The post—test is similar in design to the pre—test;
it may in fact be the same. Although different circumstances were used,
the post-test was identical to the pre-test in the present study since
the learning outcome of the instruction was to ”elicit a client's diet
history." Instructions for the post-test parallel those of the pre-test
(Appendix D). The case studies were designed according to the same
format. Two dietetic problems were selected: one for the pre-test
and one for the post—test (Appendix D). Both were equivalent in terms
of complexity. Using the identical format and a comparable dietetic
problem for the case studies served to standardize the testing situation
for comparison purposes.

Simulation was used to measure the student dietitians' per-
formance on the pre-test and post-test. Since the learning outcome
implies that the student dietitian will be able to elicit a client's
diet history, the investigator designed the pre—test and the post-test
such that their performance of taking a client's diet history could be
measured. Simulation was appropriate for assessing the student dieti—
tians' performance. With simulation, variability of the client's
behavior was eliminated. Simulation also provided a standard against
which the student dietitians' performance could be judged.

At the same time, simulation produced a close approximation
to "real life" thereby minimizing risks to real clients yet adding
relevancy. The desirability and value of simulation has been reported
in the literature (Davis et_al,, 1974; Hutter et_al,, 1977; Hoban, 1978;

Gines, 1978).

Q.— -

 

30

Ms. Holly Holdman, specialist in clinical simulation, assisted
the investigator in planning the simulated testing procedures. In
addition, Ms. Holdman recommended several individuals who had pre-
viously been employed as simulated clients in physician training in
MSU's Colleges of Osteopathic and Human Medicine. The individuals
were contacted, hired, and trained in the role of the simulated client
for the tests (Appendix E). More than one individual was trained in
a given role to prevent client fatigue since the testing was completed
for all of the student dietitians within a two-day period, for both
the pre-test and the post-test. Alternating between clients provided
the simulated client a break between interviews. Scenarios of the
simulation and "instructions for responding" were written to train
the individuals in the role of the client and to maintain standard—
ization of the test. Two male actors impersonated the client for the
pre-test while four female actresses assumed the character for the
post-test (Appendix D).

The simulated clients were given instructions to elicit
information completely, consistently, and accurately. The student
dietitians were instructed to react to the situation as they would
in real life. Time was provided at the conclusion of each interview
so that the simulated client could give feedback to each student
dietitian on her interviewing skills (Appendix F).

Development of the evaluation instrument. Evaluation of

 

students' performance is a critical component in the learning process.

A poorly constructed instrument is vulnerable to ambiguity. An

 

31

evaluation checklist designed as a rating scale was developed for
assessing performance of behaviors selected as essential to obtaining
an accurate and complete diet history (Appendix G). A performance
rating scale is effective in measuring learning in the cognitive,
affective, and psychomotor domain (Roth, 1978). The checklist was
designed to measure both the method (process component) of eliciting
a client's diet history and the information (tool component) obtained.
The University of Colorado Medical School designed a similar checklist
to teach and evaluate the interviewing skills of students in a pediatric
clerkship (Hutter et_al,, 1977). A weight of importance was assigned to
each item on the checklist according to its importance in taking an
accurate and complete diet history; the most important behaviors were
assigned greater weight than the less essential behaviors. This design
has been used with medical students to evaluate their performance on
clinical skills (Stillman et_al:, 1980). The student dietitians
received a separate score for each component (tool and process).
Competency must be demonstrated for each component for the final
evaluation. Thus, 86 percent achieved for each component implies
competency for the instructional unit, whereas a score of 76 percent
for one component and a score of 96 percent for the other component
cannot be averaged to give an overall score of 86 percent.

The rating procedure considers the four criteria of evaluation
cited by Tower and Vosburgh (1976): objectivity, reliability, validity,
and practicality. The observer who rates a learner's performance poses

a dilemma in the evaluation process. The difficulty concerns the

32

objectivity of the checklist: the degree to which there is a high
level of agreement in scores for a given performance when evaluated
by two different persons.

Initially, a list of critical items was generated by a review
of the literature. The list was examined to determine the observability
of each item. Characteristics which represented a principle were broken
down into observable behaviors which comprise the principle. For
example, Section A--Establishes a trusting relationship was analyzed
to yield a list of nine behaviors which contribute to the principle of
"Establishes a trusting relationship" (Appendix G). Once all of the
essential behaviors were identified, a method of discriminating among
the levels of performance was determined to increase objectivity. For
practicality, three levels of performance were selected for each

behavior as follows:

 

Scale
"2" - Consistently attempts to demonstrate knowledge
Satisfactory and skill with moderate or good success.
Requires additional practice to improve
performance beyond expected competency.
"1" Usually attempts to demonstrate knowledge
Fair and skill with some success. Experiences
difficulty. Requires practice to meet expected
competency.
"0” Unable to demonstrate knowledge and skill.
Inadequate Displays no attempt or minimal attempt without
success, or exhibits inappropriate behavior.
"NA" Opportunity to exhibit behavior is absent in

Not Applicable the situation.

33

A method for determining what constitutes each level was further
delineated for each behavior resulting in a set of criteria (Appendix G).
The criteria served to standardize the process of rating for accurately
assessing student dietitians' performance, and avoiding rater judgment
and prejudice. An example of the criteria for the behavior "uses
open-ended questions" is listed below:

uses open-ended questions to generate discussion in

at least four instances [Can question be answered

with (1) one word, (2) yes or no, or (3) does question
encourage verbalization?]

 

Scale
"2" Attempts at least four times to use open-ended
questions;
"1” Attempts between one and four times to use open-
ended questions;
"0" Does not attempt to use open-ended questions.

The elaborate description of the criteria is also useful to the student
in self-evaluation.

An additional response option of "not applicable" was included
as a means of eliminating from the score a behavior for which the
student had no opportunity to perform. For example, if the behavior
"probes areas where client's responses are incongruent" is not observed
due to lack of opportunity for the student dietitian to practice the
behavior, then the number of points possible for the behavior would be
subtracted from the total possible points so that the student dietitian
would not be penalized. On the back of the checklist,space was provided

for anecdotal comments. These comments provided documentation of the

 

 

 

 

 

 

 

 

 

 

 

 

34

rationale used to make changes on the checklist for improving the
checklist's objectivity.

During the formative testing of the module an attempt was made
to measure the reliability and validity of the checklist. Reliability
measures the consistency of obtaining the same results each time under
identical conditions. The checklist requires a minimum of hesitation
in rating the behaviors when used with the criteria which has been
cited as one indicator of an instrument's reliability (Tower and
Vosburgh, 1976). During the formative evaluation the same simulated
client was used, providing consistency in the data to be elicited.
Comparison among the raters verified the effectiveness of the checklist
to yield the same results in a given situation.

Validity, the concept of whether the checklist measures what
it was intended to measure, was partially determined by evaluating the
audiotapes from the formative evaluation. Higher scores were obtained
by students who completed an accurate and complete diet history. Stu-
dent dietitians receiving lower scores did not elicit as qualitative or
as quantitative data as student dietitians achieving higher scores.

Practicality was considered in the design of the checklist.
Evaluation of the student dietitians' performance during the formative
testing verified the practicality of the checklist. The checklist was
short enough to complete in the time allowed for evaluation. As a basis
for evaluation, the checklist served to provide reinforcement on the
student dietitians' performance and a basis for indicating degrees of

change from one interview to another (pre-test to post-test). These

 

 

35

characteristics comprise practicality as reported by Tower and Vosburgh
(1976).

Reliability of evaluators. One disadvantage of a rating scale

 

is that it is subject to low inter-rater reliability due to biases of
the evaluators (Roth, 1978). Inter-rater reliability was established
among three evaluators (raters) prior to the evaluation of the pre-tests
and post-tests using the evaluation checklist. The coefficient of inter-
rater reliability reflects the amount of agreement among the raters per
student dietitian and the discrimination among student dietitians by the
raters. If all of the student dietitians were given an identical score
by all of the raters, this would result in a low coefficient while their
agreement per student dietitian would be perfect. The criteria devel-
oped to correspond to each item on the checklist facilitated the dis-
crimination by the raters of the levels of performance. Four trials
were completed in establishing inter-rater reliability on the checklist.

Trial 1. Initially, the raters evaluated three of the diet
history audiotapes from the formative evaluation of the module prior
to training to determine the extent of training required. Reliability
using the inter-rater reliability coefficient (Ebel, 1951) of the
average value of the three student dietitians was r= .520. The
investigator compared the results of all of the raters and planned
the training accordingly (Figure 3).

Training was expedited, since each rater had previous experience
in taking diet histories as well as in evaluating student dietitians'

performance in taking a client's diet history, with different methods.

 

 

 

 

36

 

 

10.

11.

12.

13.

14.

15.

16.

Selection of audiotapes.
Distribution of audiotapes among raters.

Audiotapes are listened to by raters and comments are noted
on checklist.

Student's worksheet is checked for written response to
question/response on tape.

Criteria are reviewed to ensure accurate selection of
performance level for given item.

Scores are recorded for items completed.

Raters listen to audiotape a second time to complete remaining
items on the checklist.

Steps 4 through 6 are repeated.

Rater computes score for each item by multiplying level of
performance by the weight of importance to determine score
for each item.

Scores are tallied for each component: tool and process.

Score possible for non-applicable items is subtracted from
total possible points.

Percentage is figured for points achieved out of total
possible points for each component: tool and process.

Rater exchanges audiotapes with another rater for a second
tape.

Step 3 through 12 are repeated.

Steps l3 and 14 are repeated until each audiotape has been
rated.

Ratings of each rater for each audiotape are analyzed to
determine reliability coefficient.

 

Figure 3. Rating Procedure for Evaluation of Diet History Audiotape

Interviews.

 

 

 

37

The raters included a clinical instructor, a graduate assistant, and
the investigator. Training began with a discussion of every item on
the checklist with reference to the criteria identified for that item.
The rules for special cases were discussed as could be determined.

Trial 2. After the training session, each rater re-evaluated
the same three audiotapes of diet histories according to the guidelines
discussed. For authenticity in scoring, each tape was rated indepen—
dently by the raters. The tapes were listened to in their entirety,
twice. After completing the first evaluation on one tape, the raters
discussed the evaluation to verify the acceptability of the criteria.

In addition, the criteria were refined as necessary to accommodate
marginal cases. The raters recorded all other comments for later
discussion for improving the evaluation process. The inter-rater
reliability coefficient of the average value of the three raters by

the three students achieved was r= .872. The reliability coefficient
obtained for each part of the checklist was examined. Greater reliabil-
ity was achieved for the tool component than for the process component.

Trial 3. Before the third trial, the raters discussed the
results, clarified the misunderstandings, and provided input to improve
the rating criteria to reach better agreement on the ratings with empha-
sis on the process component. The third trial following the same proce-
dure consisted of four diet history audiotapes. The reliability on
these tapes for each of the possible combination of three and all four

was computed as follows:

 

 

 

 

 

   

38

121.122: 3
1, 2, 3, and 4 .384
1, 2, and 3 -.096
2, 3, and 4 .419
l, 3, and 4 .566

The decrease in rater reliability was difficult to interpret. The
raters reviewed their scores with each other and discussed the dis-
crepancies. The loss of rater reliability was attributed to the raters'
inattention to every response, since consensus was reached once the
discrepancies were reviewed. The task of listening to several tapes
is tedious. In addition, the checklist is comprehensive requiring
concentration to all responses spoken by the student dietitian and
the client. The raters strongly agreed it was essential to listen to
every tape twice in its entirety so the procedure was not changed. The
researcher recommended that the raters stop the tape at intervals for
making written comments.

Trial 4. The rating procedure was repeated with two more diet
history audiotapes. The raters evaluated the first tape together.
After the tape had been listened to and the scores tallied, the raters
discussed the score given and obtained unanimous judgment for each item
in detail. Then, each rater listened to the second tape, independently.
The correlation of the second tape was computed for each of the possible
pairs using the Pearson Product Moment Correlation and the average of
these coefficients was used to describe the inter-rater reliability of

the scores (Lindquist, 1953). The Pearson Correlation gave an average

 

 

39

reliability of r= .999. Further training at this time was not
necessary. The raters proceeded to evaluate the student dietitians'

diet history tapes.

Step 4

In Step 4, plan lesson, the instructional strategy of an
instructional unit is developed. Planning the lesson includes:

1. what you will do prior to presenting information;

2. what students will do with the information; and

3. how will the information be tested.

One component of the instructional strategy is selecting motivational
activities to obtain and maintain the learners' interest throughout

the instruction. In designing the module, cartoons and examples were
interspersed throughout the lesson to break up the information presented
into smaller segments.

Presenting information is another component of planning the
lesson which begins with determining the sequence to follow in pre-
senting the information to the students. Subordinate skills identified
in the hierarchial analysis were useful in sequencing the material in
the module since mastery of the knowledge and/or skill listed in one
subordinate skill was necessary before proceeding. The subordinate
skills were also useful in determining the size of each fragment of
material taught. Dividing the material into workable fragments led
to the designation of ten sections of the self-instructional module
listed below:

Section A Defining the diet history

Section B Identifying the need for a diet history
Section C Identifying sources for collecting dietary data

 

 

   

40

Section D Stating the purpose of the diet history

interview

Section E Discriminating between effective and ineffective
communication

Section F Discriminating content of interchange

Section G Choosing the data collection method

Section H Generating a food frequency

Section I Identifying eating behavior

Section J Generating food intake and eating behavior

data simultaneously.

Presenting information includes making decisions about what specific
information, concepts, rules, and principles should be included in an
instructional unit. Determining what specific information to include
in the diet history lesson was facilitated by relating each concept,
rule, and principle to the hierarchy leading to the learning outcome.
If the information was not critical to achieving the learning outcome,
it was omitted. For example:

Concept: identify landmarks

Is the ability to identify landmarks essential
to eliciting a client's diet history?

Decision: Yes, identifying landmarks is essential in

eliciting a complete Diet History.

Student participation is another component to an instructional
strategy. The embedded test exercises represented one method of
involving the students in the facilitation of their learning to elicit
a client's diet history. Feedback given in response to student dieti-
tians' replies reinforced the information tested by enabling them to
self-assess their comprehension of the material presented in each
section of the module. The student dietitians were instructed to
continue if they answered the test question correctly. Those students
having difficulty were given another practice exercise or instructions

to review material just presented.

 

 

41

Step 5

After planning the lesson, Step 5, construct lesson, involves
the procedure for developing the instructional package. The materials
for the diet history lesson were assembled in rough form. Once written,
the investigator reviewed the lesson to check the sequence and flow of
ideas, accuracy of material, and completeness.

At this phase of the development process, review of the self-
instructional module was solicited by members of the investigator's
Graduate Committee and faculty from two other institutions. An instruc-
tional development expert, familiar with the Hiob Model also critiqued
the instructional design. Their comments and recommendations were

incorporated prior to testing the module with student dietitians.

Step 6

The actual effectiveness and efficiency of the self-
instructional module was assessed in Step 6, formative evaluation.
Initially, a one—to-one evaluation was completed individually with
three students testing the self-instructional module. The students
selected were typical of the target population. Each student was a
Junior dietetic major with a similar academic background. The students
possessed limited knowledge of the concept of the diet history. Accord—
ing to the Hiob Model, one of the students should be slightly above
average in general ability, and another student should be slightly
below average. The students selected for the one—to-one evaluation
in the present study were not hand—picked according to general ability;
rather, volunteers were solicited to ensure an adequate number of stu-
dents for participation. The formative evaluation was conducted at the

end of the term, during finals week, a time which students were either

 

 

   

42

busy studying or were finished with exams and had left town during
break. The students' role was explained as one of an evaluator;
they were asked to react to the materials. The module designer
recorded comments elicited by each student during the time spent
working through the module. The pre-test and post-test were not
administered to the students in the one-to-one formative evaluation,
since the purpose was to determine whether a student could work
through the module unassisted.

After the one-to-one evaluation, the module was tested with
a small group. Though approximately ten students are recommended for
the small group (Hiob, 1978), more than five students representative
of the target population could not be obtained for the present study.
The students for the small group evaluation were given an explanation
about the purpose of formative testing. They were encouraged to give
feedback to be used for improving the module. The materials were
administered in the way their use was intended. Each student finished
the module without assistance. The students took the post-test follow-
ing completion of the module. None of the students achieved competency
on both the process and the tool components, but two out of five
achieved competency on the tool component. Areas in which the students

had the most difficulty were critically examined by the investigator.

Attitude Survey

 

An attitude survey was completed by the students participating
in the one-to-one and small group formative evaluation to provide the

instructional designer feedback for revising the lesson prior to the

 

43

field evaluation (Appendix F). In general, the feedback given by the
students was favorable. None of the students thought that the length
of the lesson was too long. One student indicated that "if more than
one sitting" was allowed for working through the lesson, then the
length was appropriate. The time spent completing the unit ranged
from two hours and fifteen minutes to three hours and thirty minutes.
The sections which the students had the most difficulty with were:
Section A--Defining the Diet History and Section H--Generating a
Food Frequency. One explanation for the difficulty associated with
Section A is that the students were unaccustomed to self-instruction,
as one student wrote, "till I got used to the format." Section H
was critically examined and changes were incorporated to clarify the
information presented in the section. The sections most enjoyed by
the students were: Section E--Discriminating between Effective and
Ineffective Communication and Section F--Discriminating Content
of Interchange." Generally, the examples and practice exercises
interspersed throughout the lesson and the content were liked the most
by students. In response to "what did you like least about the lesson?"
the "fill-in (the blank)” exercises appeared to distract the students
in reading the lesson for content. Changes solicited from the students
to improve the lesson included, "[add] a practice interview" and "[add]
a summary listing." Adjustments in the lesson were made based on the
responses obtained (Appendix Figure F.l).

The field evaluation (summative testing) succeeds the one-to-
one and small group evaluation. The summative testing approximates

the situation in which the finished product will be implemented.

44

> The investigator met with the participants following completion
of the study to provide feedback regarding their progress as well as

to share with them the results of the study.

Step 7
Step 7 of the Hiob Model, recycle, enables the module designer

to refine the instructional module after evaluation. The system allows
for a re-evaluation of the changes made. Thus, a module can be contin-
ually revised until the desired outcome is achieved. The present study
stops short of this step; however, the recycling issue is discussed in

Chapter VI, Limitations and Recommendations.

Development of the Lecture

 

After the self-instructional module on facilitating student
dietitians' learning to elicit a client's diet history had been devel-
oped, the investigator repeated the procedure, using the Hiob Model,
to develop an instructional unit with the same content in a lecture
discussion format. Since the topic and the research design were
identical, the methodology will focus on aspects of the development
of the lecture which differed from the development of the self-
instructional module.

The same learning outcome (Step 1) was used to develop the
lecture.

Given a simulated client and his/her medical record

the student dietitian will be able to elicit the

client's diet history with 86 percent accuracy,

according to the performance criteria.

The analysis of the learning outcome (Step 2) did not differ from that

identified in developing the self-instructional module (Figure 2).

 

45

Steps 1 and 2 are not dependent on the mode selected for
delivery. The remaining steps were influenced by the presentation
method. In Step 3, criterion referenced tests were developed. Like
the self—instructional module, the entry test was omitted. The same
pre-test, post-test, and evaluation instrument were borrowed from the
self-instructional module since the field evaluation required a depen-
dent variable for comparing the effectiveness of the treatments (lecture
and self-instructional module). Embedded tests were written to corre—
spond with the concepts and principles taught and were designed for
encouraging class discussion.

The lesson was planned (Step 4) according to the time con-
straints of a two-hour period. Motivational activities included the
use of overhead transparencies of comics which illustrated points being
discussed. From the hierarchical analysis of the learning outcome, the
investigator sequenced the material to be presented, which evolved into
an outline. The pieces of material paralleled those identified in the
self—instructional module. Student participation was facilitated with
lecture discussion format. The lesson was devised so that the instruc-
tor could ask questions to stimulate class discussion. Group dynamics
inherent in a lecture discussion format provided alternative perspec-
tives for approaching the topic which is not feasible with self-
instructional materials.

The lesson was constructed in Step 5. Outline format was used
to compile the content. Handouts for the student dietitians and trans—

parencies were included in the instructional package. The lecture was

 

   

46

reviewed with the instructor of HNF 302. The entire lecture was
examined to ensure that the instructor could present the material
as designed.

One-to-one and small group formative evaluation (Step 6) were
not conducted since it was not possible to arrange a lecture with
students and the instructor. Furthermore, the content had been tested
previously with the self-instructional module. Areas in which the
students had difficulty were examined in the lecture to insure

consistency in the content delivered.

Testing of the Comparison

 

The purpose of significance testing is to distinguish between
real differences and chance variation. The null hypothesis states that
an observed difference reflects chance variation. A significance level
of p:;.05 was selected for the present study. The significance level
represents the chance (probability) of getting a test statistic as
extreme as or more extreme than the observed one: chance being com-
puted on the basis that the null hypothesis is correct (Freedman p£_§1.,
1978).

The paired t—test was used to determine whether there was a
significant difference in achievement from pre-test to post-test for
a given treatment, attributable to instruction (Hypotheses l, 2, 3, and
4). The paired t-test is appropriate when two tests are completed on
the same group to determine difference in achievement from pre—test
to post-test, and when there is no independence between groups since

each group served as its own control. The significance level (p:§.05)

 

 

47

was divided by the number of tests (two) run on the data to yield an
overall alpha value of p:§.025 for determining the significance.

The paired t-test was not used to compare the effectiveness
between the treatment groups. The difference score analysis that
would be required assumes that without treatment the gain in achieve-
ment from pre-test to post-test in both treatments would increase
equally, thus assuming that any difference between treatment groups
is attributable to the treatment. The assumption is inappropriate.

An Analysis of Covariance (ANCOVA) was used to compare the
effectiveness between the lecture and the self-instruction groups
(Hypotheses 5 and 6) ANCOVA is appropriate for testing the hypotheses
comparing treatment groups. The ANCOVA compares the variance between
the population groups with the variance within the population groups
after equating the groups on the appropriate pre-test as the covariate.
Thus, differences between treatment groups on the post-test are appro-
priately attributable to treatment. The ratio of their variance pro-
vides the F-value. The F—test obtained was used to determine whether
the variance of the two post-tests was equal. The significance level
Q95 .05) was divided by the number of tests (two) to yield an overall

alpha value of ps;.025 for assessing the significance of the test.

 

 

CHAPTER IV

RESULTS AND DISCUSSION

In Chapter IV, the scores of the pro-tests and the post-tests
are discussed for the ten student dietitians in the self-instruction
group and the ten student dietitians having the lecture treatment.
Table 1 illustrates the scores of the pre—tests and the post-tests
for both treatment groups.

Two statistical applications were used to analyze the data.

A difference score analysis using the paired t-test was completed on
both the self-instructional and lecture groups. ANCOVA was used to
compare the self-instruction treatment with the lecture treatment.

All scores for the pre-test and post-test of the study are reported

in Table 1.

Results of t-Test

 

Four tests were run using the paired t—test to analyze the
following hypotheses:

l. MSU student dietitians given a selfLinstructional module
on eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre—test to post-test for the process component.

2. MSU student dietitians given a selfLinstructional module
on eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre—test to post-test for the tool component.

48

 

;

 

49

Table 1. Results of Pre-Tests and Post-Tests for Process and Tool
Components for Student Dietitians in Self-Instruction and
Lecture Treatment Groups

 

 

Pre-Test Post-Test

 

 

Treatment “£3 S.D.b fa S.D.

 

Self-Instruction (N==10):

 

Process 38.0 9.90 50.5 7.01
Tool 36.6 7.85 43.3 3.65

Lecture (N==lO):

 

Process 36.5 8.61 50.8 6.68
Tool 32.7 6.83 39.9 3.11
ai'= Mean.
b

S.D.==Standard Deviation.

3. MSU student dietitians given a lecture presentation on
eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre-test to post—test for the process component.

4. MSU student dietitians given a lecture presentation on
eliciting a client's diet history, will show no difference
in achievement on performance of eliciting a client's diet
history from pre-test to post—test for the tool component.

Self—Instruction Treatment Group

 

The mean score of the process component for the pre-test was
38.0 compared with a mean score of 50.5 for the post-test. Gain in
achievement was significant (p: .011) from the pre-test to the post-

test (difference: 12.5}

50

For the tool component, a significant gain (p: .007) in
achievement from the mean score of the pre-test (36.6) to the mean
score of the post—test (43.3) was observed (difference==6.7).

Student dietitians in the self-instruction group demonstrated
a significant gain in achievement for the process and tool components.

Therefore, hypotheses l and 2 were rejected.

Lecture Treatment Group

 

The mean score of the pre—test for the process component was
36.5 compared with the post-test mean score, 50.8. The difference in

achievement was 14.3, giving a significant p value of .001 (Table 2).

Table 2. t-Test Summary Statistics of Pre-Test and Post-Test Scores for
Process and Tool Components for Student Dietitians in Self-
Instruction and Lecture Treatment Groups

 

 

t-Test Summary Statistics

 

 

 

Treatment t-Value P-Value
Process:

Self-Instruction (N: 10) -s.17 .011:
Lecture (N==10) -4.93 .001
Tool:

Self-Instruction (N==lO) -3.44 .007:
Lecture (N==lO) -3.99 .003

 

3Significant at as .025.

 

51

The mean score of the pre-test for the tool component was 32.7
compared with the post-test mean score, 39.9. Gain from pre-test to
post-test was 7.2, with p= .003 (Table 2).

Hypotheses 3 and 4 were rejected; student dietitians in the
lecture treatment group demonstrated a significant gain in achievement

for the process and the tool components (Table 2).

Results of ANCOVA

 

The score for the process pre-test was used as the covariate
for the process post-test score to test for the equality of means
regarding the differences between the self-instruction group and
the lecture group in the following hypothesis:

5. MSU student dietitians given a selfLinstructional module

and MSU student dietitians given a lecture presentation on

eliciting a client's diet history, will show no difference

in achievement on performance of eliciting a client's diet

history, as measured by the identical post—test for the

process component.

The tool pre—test score was used as the covariate for the tool
post-test score to test for the equality of means regarding the differ-
ences between the self-instruction group and the lecture group in the
following hypothesis:

6. MSU student dietitians given a selfLinstructional module

and MSU student dietitians given a lecture presentation on

eliciting a client's diet history, will show no difference

in achievement on performance of eliciting a client's diet

history, as measured by the identical post-test for the

tool component.

For the process component, the significance of F as determined

from the main effects was .091. The ANCOVA showed that when the scores

 

 

 

 

 

52

on the pre-tests are taken into account, the difference between the
self-instruction group and the lecture group is not significant, based
on a==.025 (Table 3).

For the tool component, the significance of F as determined
from the main effects was .897, failing to show a significant differ-
ence in achievement between the self—instruction and lecture groups
(Table 4).

On the basis of these data, hypotheses 5 and 6 were accepted
for both the process and tool components. There is no significant
difference between the self—instruction and lecture treatment groups
in student dietitians' performance on eliciting a client's diet history.
Although there was no significant difference in achievement, it is
important to recognize that the lecture was systematically developed
for this study and for that reason may have been atypical. A lecture
carefully planned is likely to be more effective than one planned by
an instructor without using a systematic approach. The effectiveness
of a lecture is dependent on the experience of the instructor and the
time available for its preparation. Self-instruction guarantees that
the material is presented consistently the same each time, whereas the
element of human error and variation may affect the delivery of the

same material with lecture.

 

 

53

Table 3. ANCOVA Summary Statistics of Pre-Test and Post-Test Scores for
Process Component for Student Dietitians in Self-Instruction
and Lecture Treatment Groups

 

 

 

Sum of Mean Significance
Source of Variation Squares DF Square F of Fa
Covariate 109.520 1 109.520 14.259 .002
109.520 1 109.520 14.259 .002
Main effects 24.703 1 24.703 3.216 .091
24.703 1 24.703 3.216 .091
Explained 134.223 2 67.112 8.737 .002
Residual 130.577 17 7.681
Total 264.800 19 13.937

 

aSignificant at as .025.

Table 4. ANCOVA Summary Statistics of Pre-Test and Post-Test Scores for
Tool Component for Student Dietitians in Self-Instruction and
Lecture Treatment Groups

 

 

 

Sum of Mean Significance
Source of Variation Squares DF Square F of F3
Covariate 8.296 1 8.296 .169 .686
8.296 1 8.296 .169 .686
Main effects .844 l .844 .017 .897
.844 1 .844 .017 .897
Explained 9.140 2 4.570 .093 .912
Residual 835.410 17 49.142
Total 844.550 19 44.450

 

aSignificant at a:;.025.

 

 

54

Competency Comparison

 

Table 5 illustrates the achievement of the student dietitians
in both treatment groups by percentage range of post-test scores. None
of the student dietitians receiving either treatment achieved competency
(86 percent and above) on the pre-test for the tool component, while
only one student dietitian achieved competency on the pre-test for
the process component. These data were anticipated since the pre-test
was administered prior to instruction.

Following the administration of the treatment, the trend
reversed. None of the scores for either self-instruction or lecture
was below 50 percent for either the process or the tool component.

Five of the student dietitians in the lecture group and six of the
student dietitians in the self—instruction group met competency for

the tool component while only one of the student dietitians in the
lecture group and two of the student dietitians in the self-instruction
group met competency for the process component.

One explanation for the apparent difference in achievement
between the process and tool components is attributed to the type of
learning required for each. The content of the tool component requires
mastery of knowledge while the process component measures skill attain-
ment. The lack of practice in skill application may account for the

lower scores achieved on the process component (Danish, 1975).

 

 

 

55

Table 5. Number of Student Dietitians in Self-Instruction and Lecture
Treatment Groups by Range of Percentage Achievement on Pre—
Test and Post-Test Scores for Process and Tool Components

 

 

 

 

 

 

 

Lecture Self-Instruction
Achievement
(Percentage) Pre-Test Post-Test Pre-Test Post-Test
---------- Number of Student Dietitians ----------
Process:
86 and overa l l 1 2
50-85 6 9 7 8
Less than 50 _3_ _9_ _2_ _9.
Total 10 10 10 10
Tool:
86 and overa 0 5 0 6
50-85 8 5 8 4
Less than 50 _31 _Jl _;2 '_g
Total 10 10 10 10
a
Competency.

Curriculum Feedback

 

After the field evaluation, the student dietitians completed
a curriculum feedback form to determine acceptability of the lesson
(Appendix F). Their comments about the instructional design of the
diet history lesson and the tests were tabulated and are presented in
Figures F.2 and F.3, Appendix F. The overall input from the student
dietitians was favorable for the instruction both in self-instruction

and lecture formats.

 

 

56

Self-Instruction

 

In contrast to the comments received from the formative
evaluation, most of the student dietitians receiving self-instruction
felt that the length of the module was too long. The student dietitians
had asked how long it would take for them to complete the module. The
reply given to the inquiry was two and one-half hours to three and one-
quarter hours (based on the formative testing). It is likely that
the student dietitians were more anxious about the assignment than
the students participating in the formative evaluation, since the
student dietitians were to receive a grade on their performance.
Subsequently, the student dietitians may have studied the materials
more critically and devoted additional time to the instruction.
Furthermore, in comparison to the time anticipated by the student
dietitians, the module was perceived as "too long."

The section the student dietitians reported having the most
difficulty with was Section H—-Generating a Food Frequency. This
response was least anticipated since the section had been revised
for the purpose of clarifying the material presented. The sections
enjoyed the most by the student dietitians were Section I--Identifying
Eating Behavior and Section J—-Generating Food Intake and Eating
Behavior Data Simultaneously.

One explanation for the difference in responses from the
formative evaluation is that the student dietitians in the GDCSP
may have a different orientation than the students in the Conventional

Dietetic Program who participated in the formative evaluation.

57

One recommendation from the formative evaluation was to include
a summary at the end of the module. Prior to the field evaluation, a
summary was incorporated. The response of the student dietitians to
this revision was favorable. Half of the student dietitians commented
favorably on the format of the self-instructional module. As with the
formative evaluation, the examples were well liked by several student

dietitians. The length of the module was cited as "least liked.”

Lecture

In comparison, a majority of the student dietitians receiving
the lecture treatment reported the length of the lecture as appropriate,
while only two out of ten indicated that the length of the lecture was
too long. One reason the length of the lecture (one hour and fifty
minutes) may have been well received is that prior to class, the
student dietitians were aware that the entire class had been designated
for the diet history lesson. As with the self—instruction group, the
food frequency was the most difficult part of the lesson, listed by
four out of ten student dietitians. The most frequent response to
"what was most enjoyed about the lecture?” was the examples. However,
”more examplesV was also given frequently in response to ”how would you
revise the lecture?” Clearly, examples served to illustrate the

concepts and to add relevancy to the learning experience.

CHAPTER V

SUMMARY AND CONCLUSIONS

Summary

Both self-instruction and lecture were effective in facilitating
student dietitians' learning to elicit a client's diet history as deter-
mined by gain in achievement between the pre-test and post-test scores
for the process and the tool components. An ANCOVA was used to compare
the effectiveness of the two treatment groups. The findings supported
hypotheses 5 and 6, thus failing to demonstrate a significant difference
in achievement on the process or the tool components between self-
instruction and lecture methods in facilitating student dietitians'

learning to elicit a client's diet history.

Conclusions

 

The primary conclusion of the study is that self-instruction is
as effective as lecture in facilitating student dietitians' learning to
elicit a client's diet history. Furthermore, the findings illustrate
that the instructional unit as designed enabled the majority of the
student dietitians to achieve competency for the tool component as
measured by the post-test scores, while less than one-fourth of the
student dietitians achieved competency on the post-test for the process

component. Statements regarding the superiority of the instructional

58

 

   

59

unit cannot be made since the investigator could not identify any
instructional units in existence with which to compare it.

Attitudes of the student dietitians, ascertained from their
responses on the curriculum feedback towards the instructional unit,
were favorable in both self-instruction and lecture groups.

The findings of this study suggest that self-instructional
modules for content that is stable could be developed and used in
place of lectures for other topics of dietetic education, thus saving
time in classroom instruction and freeing time for the instructor to
function in other capacities. A distinct advantage is that the use
of self-instructional materials eliminates the chance of variation in
the material presented due to human error in a lecture. The standard-
ization of material ensures that all students receive the same instruc-
tion. In addition, self-instruction can be made easily accessible so

that student dietitians can review the materials at their convenience.

 

 

CHAPTER VI

LIMITATIONS AND RECOMMENDATIONS

Limitations

 

The following limitations of the study are acknowledged.

First, lecture was selected for comparison Mutfiiself-instruction,
although lecture is not necessarily the traditional method used to teach
the concept of the diet history. Rather, direct observation or the
apprenticeship model has been commonly employed to train student
dietitians.

Second, the design of the study did not include practice. In
a "real-world" application, practice would be incorporated prior to
evaluating student dietitians' performance. To accurately measure the
effect of the treatment methods separately, the investigator chose to
omit practice since constraints prevented isolated practice by treatment
group. For the present study, difference in achievement was attributed
to the variable treatment.

Third, internal validity was not assured in the study. The
student dietitians were required to participate in the study as partial
fulfillment of completing the course requirements. Student dietitians
who would rather not have participated in the study and those who may
have preferred being assigned to one treatment group over another, may
have introduced a negative attitude or bias which could not be

controlled.

60

 

61

Fourth, external validity was not assured in the study. Results
of the study are applicable to student dietitians in the GDCSP at MSU.
It is the investigator's intent that faculty from other institutions
(random population) can compare their student dietitians with the same
characteristics (i.e., academic background, dietetic program, and module)
with the student dietitians at MSU and draw conclusions regarding the
efficacy of the diet history module in facilitating student dietitians'
learning to elicit a client's diet history (Cornfield and Tukey, 1959).

Fifth, the size of the population studied posed another
limitation. Since there are only twenty student dietitians enrolled
in MSU's GDCSP, the sample size could not be manipulated.

Sixth, the type of media selected for evaluation of the student
dietitians' performance was a limitation of the study. Videotape would
have permitted an evaluation of both verbal and non-verbal interaction
between the student dietitian and the client. However, the purpose of
the study focused on verbal communication. The cost of videotape out—
weighed its benefit for the present study. Thus, audiotape was the
media selected. Client feedback on the post-test was used to evaluate
the student dietitians' performance on items that could not be assessed
with audio. Client feedback has been used effectively with medical
students to evaluate their performance on completing physical

examinations on clients (Stillman EE.§1:’ 1980).

Recommendations

 

The present study paves the way for much needed research. The

following recommendations were generated as a result of the study.

 

 

 

 

 

 

 

 

62

Instructor's Manual

 

The investigator views the development of a manual to facilitate
instructors' utilization of the self-instructional module as a necessary
adjunct to the instructional unit. The Instructor's Manual would serve
to orient faculty in employing the module in the absence of the inves-
tigator. It is recommended that a procedure for training evaluators
in the use of the checklist be incorporated in the manual, as well as

instructions for the determination of an overall performance rating.

Replication of the Study

 

Following the original research, a retest of the study on a
larger group of student dietitians is recommended to substantiate the
results obtained and lend credibility to the findings. The proposed
study may serve to establish generalizability of the results, providing
the target population is randomly selected. Although the investigator
did not directly study generalizability, the present study was described
with sufficient detail enabling faculty of other institutions to compare
their student dietitians with MSU student dietitians and assess the

applicability of the findings.

Validity and Reliability

 

Knowledge of the validity and reliability of the instructional
unit developed for the present study is a critical topic for study.
The design of the present study compared the effectiveness of two
methods of delivery for the instructional unit. Limited evidence was
obtained from which an inference of the validity and reliability can
be made. The investigator proposes that a direct approach be undertaken

to study whether the instructional unit measures what it was intended

 

 

63

to measure (validity) and whether the results obtained via the
instructional unit are replicable in identical situations (reliability).
A corollary to the proposed study is research on the validity
and reliability of the evaluation instrument for measuring student
dietitians' performance. Is the evaluation checklist valid and reli-
able in assessing student dietitians' performance? The investigator
recommends a further examination of the inter-rater reliability of
the checklist to support the evidence obtained in the present study.
The performance criteria on the evaluation checklist are
described clearly, enabling a student dietitian to assess for himself/
herself whether the learning outcome was met. Studies are needed to
look at the inter-rater reliability between the student dietitians'
self-evaluation and the educators' rating. A student dietitian's
perception of his/her performance is essential in career development
(Unklesbay and Spears, 1975; Cochran and Spears, 1980). The Essentials
for Coordinated Programs in Dietetics specify the inclusion of a plan

for student dietitians' self—evaluation in accredited programs (1976).

Design of the Instructional Unit

 

An examination of the post—test scores and curriculum feedback
from the student dietitians participating in both treatment groups
identified sections with which the subjects had the most difficulty.

In step 7 of Hiob's Model, recycle, the ongoing evaluation of materials
developed is described. The investigator recommends that the self-
instructional module be revised based on the student dietitians'

comments. Following revision, the refined version needs to be

 

 

 

 

64

recycled through the formative and summative testing steps to

determine whether the desired effects were achieved by the change.

Videotape Accompaniment

 

The development of a videotape to accompany the self—
instructional module is recommended. The purpose of the videotape
is perceived by the investigator and supported by the student
dietitians' feedback about the self-instructional module as follows:

1. to visually and audibly present critical content which
cannot be directly addressed in print;

2. to reinforce essential concepts and principles taught
in the unit;

3. to present an alternative presentation of areas identified
as difficult to grasp;

4. to provide an alternative style of learning to serve a
greater number of student dietitians with varied learning
requirements;

5. to motivate student dietitians and promote transfer by
illustrating a "good example" of the various components

in a diet history approximating the "real-world."

Design of the Study

 

The investigator recommends a redesign of the present study
to incorporate practice as a variable. Practice and feedback are
essential for learning skills (Danish, 1975). Skill acquisition

is facilitated by the incorporation of practice in an instructional

 

65

strategy where skill acquisition is identified as the learning outcome
(Bell, 1976). In an effort to avoid a confounded error, practice was
excluded so that the conclusions of the study would be solely attrib-
utable to the independent variable of treatment method (lecture versus
self-instruction). The conditions of the test situation could not
guarantee isolated practice within each treatment method, therefore
practice was withheld until the study had been completed. The effect
of practice can be studied in two ways. The student dietitians par-
ticipating in the present study could be retested to determine the
effect of practice: (I) on their improvement, and (2) attributable
to the presentation of the initial treatment method.

Other research is needed to study the effect of practice having
been incorporated into the design of a study to determine the initial
effect of practice on the effectiveness of treatment method.

Validation of the Effectiveness
of the Instructional Unit

 

 

The present study examined the effectiveness of the method of
delivery of the instructional unit. A final recommendation rec0gnized
by the investigator is the need for testing the design of the instruc-
tional unit developed (lecture or self-instruction) with the design of
another instructional unit to further ascertain the effectiveness of
the instructional unit in facilitating student dietitians' learning

to elicit a client's diet history.

 

 

 

 

 

   

APPENDIX A

WORKING DEFINITION OF THE DIET HISTORY

   

APPENDIX A

WORKING DEFINITION OF THE DIET HISTORY

I have chosen to work with the definition offered by Mason 33_

al. in The Dynamics of Clinical Dietetics. A diet history ". . . is

 

the special tool that describes the food intake and food behaviors of
a client. It includes information about food purchasing practices,
food preparation facilities, special dietary supplement intake (e.g.,
vitamin preparations), and meal patterns."

The diet history serves two functions. It describes (1) what
an individual has been and is eating, and (2) what variables influence
the food eaten. Information obtained should be both qualitative and
quantitative in nature, if it is to represent an individual's past
and present food intake.

From this data base, the diet history can be used to describe
an individual's dietary status (statement of what an individual has
been eating). The dietary status is then considered in light with
other findings (clinical, biochemical, and anthropometric) to make
statements about an individual's nutritional status (actual nutritional

condition of the individual).

66

 

   

67

Please respond to the questions below. I encourage you to make
additional comments.

1. What other data are or should be included in a definition of
a diet history?

2. Is the definition clearly written?

 

3. Does the definition convey the meaning of a diet history to you?

4. Is the definition too broad?

 

APPENDIX B

DIET HISTORY QUESTIONNAIRE

 

APPENDIX B
MICHIGAN STATE UNIVERSITY

 

DEPARTMENT OF FOOD SCIENCE AND HUMAN NUTRITION EAST LANSING ' MICHIGAN ' 4882-1
HUMAN ECOLOGY BUILDING

September 24, 1979

TO: Directors of Coordinated Undergraduate Programs in Dietetics

As a Master's Candidate in Human Nutrition at Michigan State University,
I am abOut to begin my research study. Shapiro stated in the September
1979 issue of the Journal of the American Dietetic Association that one
of the challenges that faces the Profession of Dietetics today is, "How
can we obtain accurate information about what people eat?"

I have accepted the challenge described above. Initially, I plan to
conduct a survey to identify existing instructional modules designed to
facilitate student dietitians' learning how to procure a diet history
from a client. The enclosed questionnaire will facilitate my search.

If an instructional module can be located, I will pursue it's availability
for testing in the MSU Program to establish greater validity and reliabil—
ity. In the event I am unable to locate an existing instructional module,
I will proceed to develop one and test it for validity (content) and reli—
ability (generalizable to student dietitians from another institution).

I would greatly appreciate your assistance in this proposed study. Refer
to the "definition of terms" provided to clarify any ambiguity in termin—
ologyused. Please return the completed questionnaire by October 22. A
self-addressed envelope has been enclosed for returning your response.

If you decide you would prefer not to participate in this survey, return
the unanswered questionnaire in the enclosed envelope.

Thank you for your assistance. I am appreciative of your time and c0nsider—
ation for this study.

Sincerely,

W

Joanne Jasm , R.D.
Assistant Clinical Instructor

cc: Burness G. Wenberg
Major Advisor/Directing Research

smb 68

 

 

69

DIET HISTORY QUESTIONNAIRE

The following questionnaire is designed to ascertain the existence of in—
structional modules used in a Coordinated Undergraduate Program to facili-
tate student dietitians' learning the process of procuring a diet history.

The following definitions were adopted for this survey:

1) DIET HISTORY - represents both a tool and a process.1

 

As a tool, the diet history is a descriptor of the food intake and
behaviors of a client. The description of the food intake should provide
an estimation of the average intake of an individual (what he/she has
been and is eating). Food behaviors include the individual's usual
pattern of eating. variations in his/her food habits, and variables
(occupation, lifestyle, cultural practices, etc.) which influence the
food chosen for consumption. Dietary data obtained should be both
qualitative (with regard to nutrient density) and quantitative (amount
and frequency of consumption) if it is to represent an individual's
past and present intake.

As a process, the diet history represents the method of collecting
dietary data. Both retrospective (past intake) and inspective (current
intake) data are included in the data collection phase.

 

The diet history_§grves two functions. First, it is essential in
determining an individual's dietary status, which is then considered
together with clinical, biochemical, and anthropometric data to make
statements about an individual's nutritional status. Second, the diet
history serves as a basis for nutritional care planning and counseling.

 

2) TOOL - a means to an end, as a form or method, used in performing an
operation or necessary in the practice of a profession.

3) PROCESS - a series of actions or steps followed in a sequential order.

4) PATIENT/CLIENT - the individual receiving nutritional services. These
terms are used interchangeably.

 

5) DIETARY STATUS - a statement of the assessment of an individual's diet
history compared to a pre-determined standard.

 

6) NUTRITIONAL STATUS - the health condition of an individual as influenced
by his intake and utilization of nutrients, determined from the correla—
tion of information obtained from physical, biochemical, clinical, and
dietary Studies.

 

7) INSTRUCTIONAL MODULE - a self-contained unit of instruction which provides
students with information to acquire specific knowledge and skills.

 

1 Mason, M3, Wenberg, B.G., and'Welsch, P.K. The Dynamics of Clinical
Dietetics. New York: John Wiley and Sons, 1977.

2 Christakis, 6., Ed.: Nutritional Assessment in Health Programs, Washington,
D.C.: Am. Public Health Assoc., 1973,

 

 

 

 

70

Please answer each question below.

1)

2)

3)

4)

Do student dietitians in your program use the diet history as a tool
to describe the dietary status of an individual?

Yes No
If your answer was yes, go on to question two.

If your answer was no, please indicate on the reverse side of this page,
what tool(s) the student dietitians do use.

Do the student dietitians learn the process of procuring a diet history
from a client by way of an instructional module?

Yes No
If your answer was yes, go on to question three.

If your answer was no, please describe on the reverse side of this page,
how the student dietitians learn how to procure a diet history, e.g.,
lecture presentation, simulation, field experience, etc.

Would yOu be willing to indicate how this module could be obtained or
purchased for Our consideration? If so, please complete the form below.

Name to contact

Address

 

 

 

Description

 

Cost

 

Would you be interested in receiving information on the availability or
development of the instructional module described above?

Yes No

If your answer was yes, please include your name and address below,
if you have not already provided it in question 3.

Name

Address

 

 

 

Additional Comments are welcome.

Thank you for your cooperation. Please return the questionnaire in the
enclosed envelope.

 

 

 

 

APPENDIX C

REPORT OF SURVEY FINDINGS

 

APPENDIX C
MICHIGAN STATE UNIVERSITY

 

DEPARTMENT OF FOOD SCIENCE AND HUMAN NUTRITION EAST LANSING ' MICHIGAN ° 48824
HUMAN ECOLOGY BUILDING

November 21, 1979

TO: Directors of Coordinated Undergraduate Programs in Dietetics

I am pleased to share the findings of the survey conducted on identifying
instructional modules related to the teaching of the diet history, as a
tool and a process.

To date, forty-seven of the seventy-one (66 percent) questionnaires have
been returned. The survey identified the existence of several modules
suited to the curriculum in which they have been implemented. Two of the
respondents indicated that they would be willing to share at this time
knowledge of their instructional module with Directors affiliated with
other Coordinated Undergraduate Programs in Dietetics.

1) Counseling a Newly Diagnosed Diabetic Part I Dietary History
(33 minute videotape, available for purchase in the near future).
Address letter of interest to:

Leila P. Hopkins, R.D.

Department of Food Administration
Rochester Institute of Technology
One Lomb Memorial Drive
Rochester, New York 14623

2) Interviewing Skills for the Dietitian in Patient Care
(25 page booklet, available for purchase). Address letter of
interest to:

 

Ernestine Jackson, R.D.
Assistant Professor

The University of Alabama
Box 1488

University, Alabama 35486

I have decided to proceed in developing an instructional module related to
the teaching of the diet history as a tool and a process for MSU. In this
way, I can develop one that is applicable to our General Dietetic Coordinated
Study Plan with regard to prerequisite knowledge and skills the student diet-
itians' possess. The field testing of the module will be completed by Spring
of 1980.

I extend my sincere thanks to each of you for your cooperation in conduct—
ing the survey.

Very truly yours,

éianne Jasmund, .D.

Assistant Clinical Instructor
71
cc: Burness G. Wenberg
Major Advisor/Directing Research

 

 

APPENDIX D

TESTING PROCEDURES

Pre-Test Instructions (Student Dietitian)
Post—Test Instructions (Student Dietitian)
Pre-Test Client Instructions

Post—Test Client Instructions

 

 

APPENDIX D

PRE—TEST INSTRUCTIONS

You have been assigned the task of eliciting a diet history from a
simulated client. You may refer to the client's medical record if
desired. Do not use any other reference during the interview.

This simulation closely resembles a situation you are likely to
encounter in clinical practice. Take as much time as you need.

Conduct the interview as you perceive appropriate. Dietitian/client
interactions are confidential. You should not discuss the interview
with anyone, until you and your classmates have completed the entire
instructional unit. At that time the instructor will hold a debriefing
conference to discuss the results.

For the purpose of evaluation, please take time to record on the form
provided, all data that you think is pertinent to the client's diet
history, whether it is elicited in response to a question or volun—
teered. You will be given credit for identifying data only if you
indicate your awareness of it, by noting it on the form. If you think
that something that you have listed is really not important after all,
then put a line through the data to indicate that the information is
of less relevance to this particular client's diet history.

The interview will be audiotaped to provide yOu with complete and
accurate feedback. Good Luck! Remember, this is your first attempt.

After you have completed the pre-test, you will be ready to begin the
lesson on the diet history. The pre—test measures your ability to take
a client's diet history prior to instruction. Therefore, you should
not expect to do as well as you will following instruction. The pre-
test score will be compared with the score achieved on the post-test
which you will do following the instructional unit. The difference
between the pre- and post—test scores represents the amount of learning
that takes place which is attributed to the instruction.

72

73

POST-TEST INSTRUCTIONS

You have been asked to elicit a diet history from a client. You may
refer to the client's medical record if desired. Do not use any other
reference during the interview. Everything necessary for taking a
client's diet history has been provided (Diet History Worksheet,
paper, writing utensils, food models, etc.).

Remember, for the purpose of evaluation, please take time to record
on the Diet History Worksheet or a blank sheet of paper all data that
you think are pertinent to the client's diet history. Include infor-
mation that is elicited in response to any of your questions as well
as information that is volunteered. You will be given credit for
identifying the information only if you indicate your awareness of

it by noting the information in writing. If you think that something
that you have listed is really not relevant after all, then place a
line through the statement to indicate that it is of less relevance
than other data elicited from the client. Excessive note taking
during the interview is distracting, therefore keep note taking brief
while you are with the client. After the interview, spend a few minutes
to "fill in the gaps" as appropriate before handing in your notes.
(The Diet History Worksheet is optional; you may write your notes

on a blank sheet of paper if desired.)

As before, the interview will be audiotaped. You may take as much
time as you need. With practice you will gain proficiency. Right
now concentrate on applying the knowledge and skills learned from
the instructional lesson.

Arrangements will be made to discuss the learning experience. You
will be given an opportunity to comment on any part.

 

74

SIMULATED CLIENT INSTRUCTIONS

You will be interviewed by a student dietitian who has been assigned
to take your diet history. The student dietitian will be evaluated on
his/her ability to obtain the desired information. The accompanying
scenario is a description of the character which you are to portray.
Read the description carefully. Familiarize yourself with the details
so that you will be able to respond as if you are the person described.
The instructions on the last page of the scenario explain how you
should interact with the student dietitian.

NAME:

ADDRESS:

SEX:

AGE:

BIRTHDATE:

HEIGHT:

WEIGHT:

ETHNIC
ORIGIN:

RELIGION:

MARITAL
STATUS:

CHILDREN:
PRIMARY

SPOKEN
LANGUAGE:

EDUCATION:

ADMISSION:

ADMITTING

DIAGNOSIS:

75

OBESE MALE COLLEGE STUDENT

John P. Lewis
Dormitory
Male

24

6/20/55

5'9”

233 lbs.

German descent

Protestant

Single

None

English

B.S. Math

24 hours before consultation

Low back pain (treated with traction)

 

 

76

SIMULATED CLIENT INSTRUCTIONS

John--An obese male college student

PRESENT HISTORY

You are admitted to the hospital for treatment of chronic low
back pain. Last week you went to the health center for persistent back
pain. The physician advised that you enter the hospital for treatment
with traction.

BACKGROUND (Past History)

 

You have suffered with back pain for several years. You have
been obese for as long as you can remember. You have been a student for
one year. You want to have a successful career. Your parents provide
emotional, but not financial support.

LIVING CONDITIONS

You live in the dormitory for graduate students. The dorm has a
dining room in which you eat the majority of your meals. You have a
small refrigerator in your room to keep snacks.

ECONOMIC HISTORY

Your finances are limited. You have a student loan to cover
living expenses. You received a scholarship which pays tuition and
book expenses.

SOCIAL HISTORY

Your grade point average is 3.5. You have several friends from
the dorm and from classes. Most of your friends are male. You don't
usually date. Most of your leisure time is spent reading books or
watching TV. You do not actively participate in sport or recreational
activities.

FOOD INTAKE

You enjoy eating. You usually eat at least three times per day,
plus between meal snacks. A typical intake follows:

 

Breakfast (8:00 a.m.) Lunch (12:00 p.m.) Dinner (6:00 p.m.)
Large glass fruit juice 2 cheeseburger 3 pork chops
1-2 c. cereal w/sugar 1 large serving French 1 cup potatoes or;
2 eggs fries 2 servings casserole
3 slices toast w/jelly 1 serving vegetable 3 slices bread w/butter
3 c. whole milk pie w/ ice—cream 5 cookies

2 c. whole milk 2 c. whole milk

 

77

Between meals you are likely to snack frequently on typical "snack
foods". These include: potato chips, colas, cookies, and occasional-
ly fruit. On weekends you usually go out drinking with the "guys" and
have at least four (4) beers.

FACTORS IN IMMEDIATE ENVIRONMENT:

Since you eat most of your meals in the dorm, the only food you purchase
is snack food.

MEAL PATTERNS:

Most meals are eaten in the dining room in the dorm with friends. You
might eat out two or three times a week.

FOODS OMITTED:

Coffee, tea, etc.
Many fruits and vegetables

FOOD PREFERENCES:
You love meat and potatoes (often eat second servings of each)
You prefer additional bread and milk with meals

You love snack foods

FOOD ALLERGIES:
None

FOOD INTAKE IN RELATION TO PHYSICAL ACTIVITY:

 

Main exercise is walking to and from the bus stop. You ride the bus
whenever you need to go places. You take the elevator in the dormitory.

PREVIOUS DIET MODIFICATIONS:

 

You have tried to lose weight by fasting With no success. You have gone
on every diet that comes out in the press. You have difficulty adhering
to any diet for longer than two weeks. Your doctor has told you to lose
weight, but never told you how to accomplish it.

SOURCE OF NUTRITION INFORMATION

 

Popular magazines and TV advertisements
ATTITUDES ON FOOD:
I. realize its importance for health

2. understand it aggravates your weight problem
3. love to eat, but hate to diet

 

   

78

SPECIAL INSTRUCTIONS

 

The instructions for conveying the information are as follows:
1. Answer questions with answers provided.

2. If a question is asked that you don't know how to answer,
ad lib the best you can. (Note ad lib comments on sheet,
after interview.)

3. Be somewhat guarded with information. Do not talk freely
unless interviewer encourages you to do so.

4. If question requires a "yes" or ”no" answer, give only
that reply until encouraged to continue.

5. If interviewer asks you a question in which an answer is
implied, give the intended answer even if it contradicts
your "story."

6. If the interviewer gives you an opportunity to elaborate
on a topic, do so. Occasionally, use this situation to
stray from the topic to an unimportant one.

Try to put yourself in the client's situation. React as you feel
is appropriate.

 

79

SIMULATED CLIENT INSTRUCTIONS

You will be interviewed by a student dietitian who has been assigned
to take your diet history. The student dietitian will be evaluated on
his/her ability to obtain the desired information. The accompanying
scenario is a description of the character which you are to portray.
Read the description carefully. Familiarize yourself with the details
so that you will be able to respond as if you are the person described.
The instructions on the last page of the scenario explain how you
should interact with the student dietitian.

 

 

NAME:

ADDRESS:

SEX:

AGE

BIRTHDATE:

HEIGHT:

WEIGHT:

ETHNIC ORIGIN:

RELIGION:
OCCUPATION:
MARITAL
STATUS:
CHILDREN:
PRIMARY
SPOKEN
LANGUAGE:
EDUCATION:
ADMISSION:

ADMITTING
DIAGNOSIS:

8O

MALNOURISHED YOUNG WOMAN

Sarah Moore

Low Income Housing Project (lives alone)
Female

37

4/15/42

5'7%”

108 lbs. (previous weight=:l45 lbs.
presently losing 3 lb. per week without
trying

German descent

Protestant

Works at gift and craft shop (sales and
clerical work)

Divorced (had been married 18 years)

None

English
High School Diploma

24 hours prior to consultation

Weight loss, malnutrition

 

81

SIMULATED CLIENT INSTRUCTIONS

Sarah—-A malnourished young woman
PRESENT HISTORY

You are admitted to the community hospital for ”tests." You went to
the Red Cross last week after work to donate blood and were not
accepted. When you asked what was the reason for refusal, you were
told that you are ten pounds below the lower limits of an acceptable
weight. The following morning, while discussing the situation at work,
your employer stated that he thought you should go see a doctor to make
sure nothing was wrong. He indicated that you have been very lethargic
and pale for some time.

You took your employer's advice and made an appointment with your
physician. Your physician said she would like to run a few "tests"
on you at the hospital. She indicated that you would probably be in
the hospital a few days.

BACKGROUND (Past History)

 

You have been employed since high school at the Craft Shop. Your parents
are deceased. After high school, you married a fellow you had dated for
one year. Last year you filed for divorce. You have no children.
Recently, a cousin your age passed away suddenly from a heart attack.
Your friend at the Nutrition Center is convinced that your cousin's

diet must have been deficient in Vitamin C and contained excessive
quantities of food preservatives and additives.

LIVING CONDITIONS

You live in a small one bedroom apartment. It is a low income housing
complex. You have adequate kitchen facilities which include common home
appliances.

ECONOMIC HISTORY

You are making minimum wage. You are just making ends meet. You have
no outstanding debts.

SOCIAL HISTORY

You have several friends from work with whom you socialize. Your best
friend works down the street at the health food Nutrition Center. She
is an adamant follower of the health food movement. She has convinced
you that natural organically grown foods are more nutritious than

store bought processed foods. You have purchased several paperback
books from the Nutrition Center. You are not familiar with the authors.

 

 

 

 

 

82

FOOD INTAKE

 

Your appetite is fair. You are accustomed to eating only two meals
per day. You have been on a vegetarian diet for approximately 1% years.
You omit meat, yet you will eat some dairy products. A typical intake
follows:

 

 

 

Breakfast (8:00 a.m.) Lunch (11:30 a.m.) Dinner (6:00 p.m.)

Once a week you may eat % cup orange juice Large fresh vegetable

approximately 2 cup 3—5 stalks of celery salad; or

bran flakes with about w/2 Tbs. peanut 1-2 oz. cheese

% cup skim milk butter 1 slice whole wheat
3-4 crackers bread

% cup sunflower seeds 1 small apple

Since your cousin's death you have taken additional measures to avoid
foods containing additives and preservatives, choosing a "natural" diet.

FACTORS IN IMMEDIATE ENVIRONMENT

 

You buy many of your foods at the Nutrition Center. It is more expen-
sive, but you want organically grown foods. You always take a vitamin
and mineral supplement that your friend recommended.

MEAL PATTERNS

 

Usually eat meals at home in the kitchen alone

You rarely snack, except occasionally (yogurt or fruit)

Eat out once in a while with your friend

Eat only in response to hunger rather than at regular intervals

FOODS OMITTED

 

All meat and meat analogs (substitutes)

Milk, except use skim milk on cereal

Eggs, unless cooked in foods

Fatty or greasy foods

Alcohol--usually (maybe 1—2 glasses of wine per month)

FOOD PREFERENCES

 

All fruits and vegetables

Cereal

Bread, whole wheat or other whole grain
Peanut butter

Cheese

Yogurt

 

7

 

 

83

FOOD ALLERGIES

 

None

INTAKE IN RELATION TO PHYSICAL ACTIVITY

 

Activity suppresses appetite; usually eat before activity
Activity consists of: jogging 2 miles daily; walking and bicycling
daily-—since don't own car.

PREVIOUS DIET MODIFICATION

 

Not following a modified or restricted diet at present. Two years ago
your doctor placed you on a "no salt" diet for about three months since
you seemed to be "retaining water." You have not experienced water
retention recently.

SOURCE OF NUTRITION INFORMATION

 

Paperback books and magazines describing the natural health food
movement from the Nutrition Center. Subscribe to Prevention magazine.
Peers, self-made nutritionists.

 

ATTITUDES ON FOOD AND NUTRITION

 

considers it important-~the secret of maintaining youth
enjoys eating

convinced that meat is bad for you

thinks food additives cause more problems than they solve
never viewed self as overweight

U'I-bOQNI—l

SPECIAL INSTRUCTIONS

 

The instructions for conveying the information are as follows:

p—i

Respond to questions with answers provided

2. If a question is asked that you don't know how to respond to,
ad lib the best you can. (Note ad lib comments on sheet, after
interview.)

3. Be somewhat guarded with information. Do not talk freely unless
interviewer encourages you to do so.

4. If question reqUires a ”yes" or "no" answer, give only that
reply until encouraged to continue.

5. If interviewer asks you a question in which an answer is implied,
give the intended answer even if it contradicts your ”story."

6. If the interviewer gives you an opportunity to elaborate on a

topic, do so. Occasionally use this situation to stray from the

topic to an unimportant one.

Try to put yourself in the client's situation. React as you feel is
appropriate.

 

   

APPENDIX E

SIMULATED CLIENT CONSENT FORM

 

APPENDIX E

MICHIGAN STATE UNIVERSITY

General Dietetic Coordinated Study Plan
(GDCSP) "

State of

 

County of

 

I, A F ,hereby agree to participate
in an educational program for Michigan State University Dieteticstudents. I
will act in the capacity of Simulated Patient in order that Dietetic students

may

 

I understand that my participation is for the express purpose of Dietetic educa—
tion through the GDCSP Michigan State University. I recognize the
sum of $ per . to represent fair and complete remmeration

for this service.

 

 

This consent has been fully explained to me. I am in agreement with its intent
and purposes.

 

Signature of Simulated Patient

 

 

Witness . Date

84

 

 

 

APPENDIX F

FEEDBACK

SIMULATED CLIENT FEEDBACK

ATTITUDE SURVEY

CURRICULUM FEEDBACK--LECTURE

CURRICULUM FEEDBACK--WORKBOOK

 

 

 

(student's name)

APPENDIX F

SIMULATED CLIENT FEEDBACK

Please comment on each of the following non-verbal behaviors
demonstrated by the student dietitian.

'U
0
O
H
’1']
p:
H
H

Satisfactory

 

 

established eye contact

smiled spontaneously . . .
maintained comfortable physical distance .
displayed natural postures and gestures
avoided nervous gestures . . . . . . . .

Did the student dietitian make you feel at ease during the interview
(convey genuine concern for you)? (Please describe.)

Did the student dietitian encourage you to completely tell your
story? (Please explain.)

Did you feel "cut off" or interrupted while responding to a
particular question? (Please comment.)

Did the student dietitian guide the interview smoothly from one
comment or topic to another? (Please describe.)

List any of the student dietitian's strengths as you perceived them.

What suggestions can you give the student dietitian to improve her
skill of taking a client's diet history?

Additional comments:

85

 

H
I

 

 

the
You

2)

3)

4)

5)

6)

7)

86

ATTITUDE SURVEY

Please respond to the following survey. Your input will assist
author in revising the workbook. Your comments are appreciated.
may select more than one statement where it is appropriate.

The length of the workbook is:

a. too short
b. satisfactory
c. too long

The degree of difficulty of the workbook is:
a. too easy

b. appropriate
C. too difficult

l

The process of completing the workbook is:

a. boring
b. interesting
c. fun

i-3

he cartoons are:

a. distracting
b. interesting

Color—coding the workbook:

____a. makes it interesting
___ b. makes it easier to read
___ c. makes no difference
___ d. is distracting

The section I had the most trouble with is:

 

 

The section I enjoyed the most is:

 

 

 

   

87
8) The practice exercises are:

a. a waste of time

b. fun to do
c. very helpful

9) The tests measure the content of the material:

a. did
b. did not

10) What did you like most about the workbook?

 

 

 

11) What did you like least?

 

 

 

12) If given an opportunity to revise the workbook, how would you change it?

 

 

 

 

88

 

 

Please respond to the following survey. Your input will assist the
author in revising the workbook. Your comments are appreciated. You
may select more than one statement where it is appropriate.

1. The length of the workbook is:

a. too short '
b. satisfactory (T111 111*)—316 completed tn mane than one
c. too long Aitting.

2. The degree of difficulty of the workbook is:

a. too easy

b. appropriate (fle 111)
c. too difficult

3. The process of completing the workbook is:

a. boring

b. interesting (T111 111)
c. fun

4. The cartoons are:

a. distracting
b. interesting (i441 111*)--*Gneat!

5. Color-coding the workbook:

a. makes it interesting ’ ‘
b. makes it easier to read (1111 111*)--*and eaAten to 64nd
c makes no difference anbwehb.
d is distracting
6. The section I had the most trouble with is:

A (11*!)er I got (used to the flower/t.

D (1) E (1) H (11)

7. The section I enjoyed the most is:
E (111) F (111)
11(1) .1 (1) Any ma exampfiezs (I)

 

 

Figure F.1 Tabulation of Responses on Attitude Survey.

 

 

 

89

 

10.

11.

12.

The practice exercises are:

a. A waste of time
b. fun to do
c. very helpful (1447' 11)

___——

The tests (1&1 measure the content of the material:
____a. did (1111 1)
___ b. did not
What did you like most about the workbook?
Content (11) Taptc (1)
Examptu (11) Spaeéng 06 sectéom (1)
Pnacttce exetetbet (1) Comptetenetb (1)

What did you like least?
Length ("4'5 I'm hand deAde to amaze/L) (1)
Gneen catch (1)
FILE-tn guebtéows (11)

If given an opportunity to revise the workbook, how would you
change it?

Improve Apaeéng and mechantcat Q/ULO/US (1)
[Add] a 'pnactéce' tntenutew (1)
[Addlgaummany tinting (11)

Take out (ta—tn guuttom (1)

Edd] mote examptu; tent fiat-tn (1)

 

 

Figure F.l--Continued

 

  

 

CURRICULUM FEEDBACK - LECTURE PRESENTATION

Please respond to the following questions. Your input will assist the in-
structor in improving the lecture presentation. Your comments are appreciated.

1) The length of the lecture presentation was:

a) too short b) satisfactory c) too long
2) The pace that the material was presented was:
a) too slow b) appropriate c) too rapid

3) The degree of difficulty of the material presented was:

a)_____ too easy b)______appropriate c)_____ too difficult
4) The lecture presentation was:

a)______boring b)_____ interesting
5) The visual aids were:

a)_____ distracting b)_____ contributory
6) The practice exercises were:

a)_____ unnecessary b)_____ helpful

7) The part of the presentation I had the most trouble understanding was:

 

 

8) The part of the presentation I enjoyed the most was:

 

 

9) If given an opportunity to revise the lecture presentation, how would
you change it?

 

 

 

 

 

90

 

 

91

 

 

Please respond to the following questions. Your input will assist
the instructor in improving the lecture presentation. Your comments
are appreciated.

1. The length of the lecture presentation was:

a. too short
b. satisfactory (T111 111)
c. too long (11)

2. The pace of the material presented was:

a. too slow
___.b: appropriate (1111 1111)
____c. too rapid (1)

3. The degree of difficulty of the material presented was:

a. too easy
b. appropriate (T111 1111)
c. too difficult (1)
4. The lecture presentation was:
a. boring (1)
b. interesting (T144 1111)

5. The visual aids were:

a. distracting

b. contributory (T141 1111)
6. The practice exercises were:

a. unnecessary

::::b. helpfu1 (T144. T141)

7. The part of the presentation I had the most trouble understanding
was:

I unde/wtood aft poatéonzs My weUi (1)
CaOAAchech (1111)
Pant about eating behavtou . . . it £2234 lat/Latghtfioawand (1)
Examptu 06 good/bad method»: 06 aahtng guest/tows (1)
How to ptece the whote dtet htotoay togethe/L (1)
How to handte the cttent'a fattaeéu. . . . I unde/wtand
how to went/{fig them but not what to do next (1)

 

 

Figure F.2 Tabulation of Responses on Curriculum Feedback--Lecture.

 

 

 

92

 

 

8.

9.

The part of the presentation I enjoyed the most was:
Ute 06 exampteA to hetp ctantfiy tome 06 the potntA made (1)
Gotng oven the tap methods 05 data cottectton . . . veny
hetpéut tn exptatntng punpote 06 dtet htttony (1)
Vantabteb tnétuenctng cttentt 600d tntahe (1)
Examptu and pnacttce exact/seas (1)
Commantcatton. . . . (1)
Pnebentatton wan ctean and conctne (on moat pant (1)
Gotng thnough actuat 24 hoan necatt (1)

 

If given an opportunity to revise the lecture presentation, how
would you change it?

Pneaentatton wan wett ongantzed and btnatghtfionnund . . .
pant I flound dtfifitcutt wat the tength (1)

Mone exampteA (1)

Lena detatt. . . . (1)

Stow down, uatng mone exampteb and havtng at aetaatty do
the netponAQ/s (1)

Mone examptet 06 ntght and wnong appnoachea (1)

See a Ahont fittm on an actuat dtet htttong, one whtch
pnenentn vantoun Attuattont that may antne. . . . (1)

 

 

 

Figure F.2—~Continued

 

 

 

CURRICULUM FEEDBACK — WORKBOOK

Please respond to the following questions. Your input will assist the author
in revising the workbook. Your comments are appreciated.

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

11)

The length of the workbook is:

a) too short b) satisfactory c) too long

The degree of difficulty of the workbook is:

a) too easy ' b) appropriate c) too difficult

The process of completing the workbook is:

a) boring b) interesting

The cartoons are:

a) distracting b) contributory

Color-coding the workbook:

a) makes it easier to follow b) makes no difference

The practice exercises are:

a) unnecessary b) helpful
The section I had the most difficulty with is Section .
The section I enjoyed the most is Section

In general, what do you like most about the workbook? (i.e. content,
format, practice exercises, examples, etc.)

 

 

In general what do you like least about the workbook?

 

 

Additional Comments:

 

 

 

93

 

 

94

 

 

1.

Please respond to the following questions. Your input will assist
the author in revising the workbook. Your comments are appreciated.

The length of the workbook is:

a. too short
b. satisfactory (11)
c. too long (111+)

The degree of difficulty of the workbook is:

a. too easy
b. appropriate (1441’ 111)
c. too difficult

The process of completing the workbook is:
a. boring
b. interesting LL11? 11)
The cartoons are:
a. distracting
b. contributory (441+ 111)
Color-coding the workbook:

a. makes it easier to follow (4111' 111)
b. makes no difference

The practice exercises are:

___ a. unnecessary
__ b. helpful (+1—1-1- 111*)-—*the dinecttonzs 06 dome ane a
We uneentatn.
The section I had the most difficulty with is Section
Identtfiytng tandmanht (1); None (11); H (11); I (1);

E (1).

 

The section I enjoyed the most is Section
Identtfiflcng tandmanh/s (1); .1 (11* )——*Seemed to put tnfion-
matton togethm; G (1); The onus on anea/s to couen (1);

 

 

TH”; E (1).

 

Figure F.3 Tabulation of Responses on Curriculum Feedback——Workbook.

 

 

 

95

 

 

9. In general, what do you like most about the workbook? (i.e.,
content, format, practice exercises, examples, etc.)
Sammany at bach 05 modate. (1)

Fonmat, pnacttce exencttet, and genenat content.
Sectton H wan weak. (1)

l tthed how tt wan dtvtded tnto a step-by-ttep tectton;
atto pnacttce exenctAeA. 1)

Exampteb wene veny hetpfiut and cneattue . . . mone woatd
be atefiut; euatuatton Aheet wan extnemety utefiut, tt
attowed me to pnacttce by myteté, ctantfited tnfionmatton.
(1)

Too tong, but tnfionmatton tn comptete. (1)

Examptea, (onmat, good cantoonA. (1)

Pnacttce exenctset and exampten. (1)

Fonmat and examptet. (1)

Fonmat, examptet, Aetfi-tetttng bectton wtth Aapptementat
antwent. (1

Moduten, tndependent ttudy, have tnoabte fitndtng time. (1)
10. In general, what do you like least about the workbook?

Have a flew quetttont that cannot be antwened [by tetfi]. (1)

Length. (111)

Length and nepetttton 06 tnfionmatton. (1)

11. Additional comments:

Supptted a tot 06 theony but wan ttmtted tn pnacttcat
tnfionmatton.

Good job!

Veny good wonhbooh.

The handebt Aectton wan H (Food Fneqaency).1 have no
pnevtout expotane to t

15 we get to keep thtA boohtet, I thtnh tt wttt come tn
handy. I tthe the appendtcet.

Mone hetpfiut t5 mone examptet tn Sectton I.

 

Figure F.3——Continued

 

 

 

 

APPENDIX G

DIET HISTORY EVALUATION

1. PERFORMANCE CHECKLIST

2. PERFORMANCE CRITERIA

 

 

 

 

APPENDIX G

DIET HISTORY EVALUATION

EXPLANATION OF USE OF FORM

The Diet History Evaluation is designed to assess students' performance
of taking a client's diet history following instruction. The purpose

of the checklist is to reinforce strengths observed as well as identify
areas in which performance needs improvement to meet expected competency.
The checklist is organized into two components. The first component in—
cludes an identification of the behaviors which relate to collecting
dietary data (process). The second component identifies behaviors which
relate to the dietary data Obtained (tool). Performance on each compo—
nent should be assessed separately, yielding two final scores rather
than an overall score.

 

WEIGHT OF IMPORTANCE/LEVEL OF PERFORMANCE

The observable behaviors represent the performance criteria, evidence
characterizing the skill being appraised. Each behavior has been weighted
according to its importance in relation to eliciting accurate and complete
data. Behaviors most critical to the diet history carry greater weight
than behaviors less crucial.

The level of performance measures how successful each behavior is com-
pleted. The scale is devised for initial expectations of performance.
After additional practice a higher level of performance will be required
and will be reflected in the scale.

SCALE

2 - Satisfactory: Consistently attempts to demonstrate knowledge and
skill with moderate or good success. Requires addi-
tional practice to improve performance beyond expected
competency.

l ‘ Fair: Usually attempts to demonstrate knowledge and skill
with some success. Experiences difficulty. Requires
practice to meet expected competency.

0 ' Inadequate: Unable to demonstrate knowledge and skill. Displays

no attempt or minimal attempt without success, or ex-
hibits inappropriate behavior.

NA — Not Applicable:0pportunity to exhibit behavior is absent in the situ-
ation.

96

 

 

97
EXPLANATION OF DETERMINATION OF SCORE

TOTAL POSSIBLE SCORE

 

The total possible score for each component (Tool and Process) is
computed as follows:

Multiply the maximum level of performance times the maximum weight of
importance for each behavior exhibited. The sum total is the total
possible score. For example, note the first behavior listed under A.
Establishes a trusting relationship;

 

... introduces self to client stating own name and position

If the student succeeds in introducing him/herself by stating both their
name and position, the student should receive a "2" for the level of
performance. On the other hand, should the student state only his/her
name and not their position, then the student would receive a "l" for the
level of performance. The student who fails to state his/her name and
position is given a "0". On the score sheet the weight of importance
for this particular behavior is "I". For the student who performs at
the upper level of performance the total score for the behavior would be
"2" ("2" x "1"). The same method would be used to determine the score
for the other levels of performance. Continue to compute the score for
each behavior as illustrated. The sum of these scores represents the
total score possible.

When all behaviors are observed at the maximum level of performance, the
total score possible is 62 points for each component (process and tool).
This score varies if certain behaviors are "not applicable" in a given
interview. For behaviors scored "not applicable", subtract the maximum
possible score (level of performance x weight of importance) for each be—
havior that is "not applicable" from the total number of points possible.
This score represents the total possible points for that particular in-
terview. The percent is figured by dividing the total score achieved by
the total possible score.

SCORE ANALYSIS

*
The diet history as a PROCESS SCORE
(total points)
A. Establishes a trusting relationship 16
B. Demonstrates interpersonal communication skills 26
C. Guides the interview 20
TOTAL 62 T 53 points = 86%)
*
The diet history as a TOOL SCORE
(total points)
D. Uses the medical record 4
E. Gathers complete and accurate data 58
TOTAL 62 T 53 points = 86%)

Maximum number of points possible

+ Minimum passing score: 86% in each category

 

98

 

Key:
2= Satisfactory
l= Fair

0: Inadequate
NA = Not applicable

 

 

 

PERFORMANCE CRITERIA

Weight of
Importance

 

Level of
Score Performance The Diet History as a PROCESS (A, B, C)

 

16 points

possible A. ESTABLISHES A TRUSTING RELATIONSHIP

o Introduces self to client stating own name ( ) and position ( ).

 

Uses client's name initially ( ) and at least one other time ( ).

 

0 Includes family members if appropriate.

 

o—ar-IHH
o

0 Prepares the environment (seating, lighting, ventilation,
distractions).

 

0 Smiles/maintains eye contact /physical position facing client.

 

0 Speaks in pleasant voice.

 

Uses common language (explains technical or unfamiliar terms).

 

HHD—IH
o

0 Explains purpose for obtaining diet history.

 

Sub—Total

 

26 points
possible B. DEMONSTRATES INTERPERSONAL COMMUNICATION SKILLS

4 0 Uses open-ended questions to generate discussion in at least four
instances ( , , ,

 

2 . Uses closed-questions for obtaining specific detail ( ) and for
clarification ( )- [__, __J . . . . . . . . . .

 

I

1 . States questions clearly and concisely.

 

3 . Uses at least three of the following:
Key: level of performance: 2
level of performance: 1
level of performance: 0

 

3+ applied
2 applied
1 applied

____encouragement ___ empathy
___ exploratory ____self-disclosure
____restatement ___ confrontation
interpretation ___ silences/pauses
3 0 Displays no more than two of the following:
Key: level of performance: 2 = 0-2 exhibited
level of performance: 1 = 3-5 exhibited

level of performance: 0 5+ exhibited

, , interrupting client while s/he is speaking
wording question with answer implied
combining two questions into one
monopolizing discussion

expressing own attitudes, values, bias
depends on verbal crutches

 

Sub-Total

 

20 points
possible C. GUIDES INTERVIEW

0 Provides client an opportunity in the beginning to state his/her problem.

 

° Encourages client to tell story fully.

 

0 Resists client's discussing irrelevant topics.

 

0 Generates questions to lead client to another area systematically.

 

0 Probes areas where client's responses are incongruent.

 

Identifies landmarks.

 

0 Directs interview at a comfortable pace.

 

0 Responds with appropriate feedback to verbal and non-verbal cues.

 

0 Summarizes interview at appropriate intervals ( , , ).

 

H H H 5.: H .... p... H H p—a
0

° Closes interview [prepares client for closure ( ), plans next contact ( ).]

 

Sub-Total

 

 

 

points ___} TOTAL SCORE-~PROCESS performance criteria (sum of sub-total A, B. and C).

 

 

 

99

 

2e=y Satisfactory
1=p
o:
A:

In ade mq
N Not applicable

 

 

 

PERFORMANCE CRITERIA
Weight of
Importance

 

Level of
Score Performance The Diet History as a TOOL (D, E)

 

4 points
possible D. USES THE MEDICAL RECORD AS DATA BASE SOURCE PRIOR TO INTERVIEW

 

2 . Uses pre- interview data from the medical record in at least two
Sub—Total instances (_ ).

 

58 points
possible E. COLLECTS ACCURATE AND COMPLETE DATA

0 Uses the 24 hour diet recall or usual food intake record to identify:

 

~ What the client eats and drinks, probing until the client states
5 that nothing else was eaten

 

‘ How much the client eats and drinks (uses food models to estimate
portion: cups, pounds, etc.), for at least half of the foo
2 items generated.

 

- Food preparation methods for at least one—half of the food items
2 generated

 

0 Classifies food intake data with food frequency and verifies it
against the 24 hour diet recall or usual food intake record in at
6 least three instances ( , ,

 

. Determines eating behavior by identifying information for at least
five of the following variables

Check ( /) variables identified.

 

Do not tally score for more than five variables. For 5+, tally
score for the five variables receiving highest rating.

food purchasing (who procures food/food and money available/
3 family income/communit) sources).

 

3 food preparation and storage (facilities, who prepares meals).

 

living conditions (number in family, lifestyle, variations in
3 daily rout 1ne).

 

eating setting (home/away from home; kitchen/while watching TV,
etc.).

 

(

eating patterns (time food is eaten, frequency of eating, food
3 eaten alone or with others).

 

3 physical activity (recreational/work-related).

 

physiological factors (appetite, food allergy/intolerance,
3 chewing/swallowing difficulty, c).

 

psychosocio factors (attitudes and values, motivation, personal
and emotional influences;food eaten for hunger,pleasure, status,
3 reward, etc.)

 

cultural influences (food symbolism, preferences, avoidances in
relation to ethnic and religious practices; language barriers;
etc.).

 

nutrition knowledge (source of information/misinformation).

 

vitamin/food supplement usage (type, amount, duration).

 

0104b!“

 

drug intake (alcohol, laxatives, antacids, medications).

previous diet modifications (type, duration, reaction, history
of compliance, effectiveness).

LN

 

~ States questions that relate to the purpose of the diet history
the majority of the tim

 

Sub-Total

 

 

points % TOTAL SCORE--TO0L performance criteria (sum of D and E).

 

 

 

 

100

Name Date

 

 

Comments:

 

 

Evaluator's signature/date Student's signature/date

 

 

   

101

CRITERIA FOR DISCRIMINATI'NG LEVEL OF PERFORMANCE

A ESTABLISHES A TRUSTING RELATIONSHIP
... introduces.se1f to client stating own name and position
2 - states both name and position
1 - states either name or position
0 - does not state name or position
... uses client's name initially and at least one other time
2 - states client's name at least twice during interview
1 - states client's name only once
0 - does not state client's name during interview

... includes family members if appropriate

(not applicable - for simulation)

... prepares the environment

(not applicable - for simulation)

... smiles/maintains eye contact/ physical position facing client

(provided by simulated client)

... speaks in pleasant voice

2 - speaks in appropriate volume and suitable (cordial) tone
1 - Speaks in appropriate volume or suitable (cordial) tone
0 - speaks in an inappropriate volume and unsuitable tone (expressionless)

... uses common language

2 — initially explains technical terms when used
1 — explains terms when asked for clarification by client
0 - does not use common language or uses technical terms with no explanation

 

102

B DEMONSTRATES INTERPERSONAL COMMUNICATION SKILLS

OHM

...:

uses openuended questions to generate discussion in at least fi_instances
(Can question he answered with 1) yes or no, 2) one word; Does question 3)
encourage verbalization?)

attempts at least 3 times to use open-ended questions

- attempts between I_and fl_times to use open-ended questions
- does not attempt to use open-ended questions

uses closed questions for obtaining specific detail and for clarification

- uses closed questions for obtaining specific detail and for clarification

when necessary (follow-up for detail, etc.)

- uses closed questions in at least §_instances that open-ended questions

would best elicit data

- uses.closed questions more frequently than open—ended questions and inappro-

priately at that.

states questions clearly and concisely

states questions easily understood and to the point as evidenced by the client's
ability to respond without further clarification

'states questions that are either clear 0? concise

states questions that lack clarity and conciseness as evidenced by client's in-
ability to respond apprOpriately or asking for clarification (more than §_times)

useS’at least 3 of the following responses...

uses 2_or more of the various responses
uses 2_of the various responses
uses only 1 of the various reSponses

displays no more than 2 of the following behaviors...

displays 2_or less of any one or more of the various behaviors
displays between 3 and §_times any one or more of the various behaviors
displays §_or more of any one or more of the various behaviors

 

 

C.

103

GUIDES INTERVIEW
#

... provides client an opportunity in the beginning to state his/her problem

2 - initially encourages client to begin discussion regarding his/her problem/concern
l — initially ecourages client to start talking in general, or encourages client

to discuss her/her problem/concern at some point during the interview
0 - does not seek to elicit client's perception of his/her problem/concern at all

... encourages client to tell story fully
2 - encourages client to generate the majority of the interaction

1 - responses are similarly distributed between client and dietitian
0 - dietitian dominates interaction

... resists client's discussing irrelevant topics ( if applicable)

2 — successfully redirects client's responses as appropriate

1 — makes little attempt to redirect client with some success

0 — does not redirect client in responding; or consistently interjects own
irrelevant comments
generates questions to lead client to another topic systematically

2 — successfully leads client from one topic to an unrelated one

1 — leads client from one topic to an unrelated one with some diffuculty

0 .

— leads client from one topic to another one wlthout completing discussion of
former one

... probes areas where client's responses are incongruent (if applicable)

2 - confronts or questions client about discrepancies to clarify data obtained
1 — occasionally attempts to ascertain accuracy of client's responses with difficulty
0

— acknowledges all of client's responses without discriminating accuracy from
inaccuracy

... identifies landmarks

2 - investigates client's responses which may be important to his/her food intake
to obtain additional information

1 - acknowledges awareness of information elicited by noting comments, but does not
pursue topic for additional detail

0 — does not acknowledge awareness of client's response or investigate topic at all

... directs interview at a comfortable pace

2 - directs interview at a pace which is apprpriate for client as evidenced by
lack of interruptions and lack of excessive pauses

1 - directs interview which is either too fast or too slow but
attempts to adjust pace appropriate for client

0 — unable to direct interview at a comfortable pace

 

 

104

... responds with apprOpriate feedback to verbal and nonverbal cues

2 — acknowledges client's responses and gives information as apprOpriate

1 - inconsistently acknowledges client's responses appropriately, or gives either
too much or too little information for the situation; or occasionally gives
untimely or inaccurate information

0 — rarely acknowledges client's responses or frequently gives untimely or inaccur-

ate information

... summarizes interview at appropriate intervals

2 - consistently summarizes interview to some extent in at least §_instances at
appropriate interVals (ie. after each meal description, etc.)

1 - occasionally summarizes data obtained about various topics (once or twice)

0 — does not summarize client's responses at all

... closes interview

2 - prepares client for closure and makes arrangements for next contact.
1 - either prepares client for closure or makes arrangments for next contact

0 - neglects to prepare client for closure and make arrangements for next contact

D. USES THE MEDICAL RECORD AS A DATA BASE SOURCE PRIOR TO THE INTERVIEW

... uses pre—interview data from the medical record

2 - makes reference to the medical record at least twice and notes comments
1 - makes reference to the medical record at least once

0 - does not demonstrate knowledge of any information obtained from the medical record

E. GATHERS ACCURATE AND COMPLETE FOOD INTAKE DATA

... identifies what the client eats and drinks

2 — determines client's food intake probing until the client states that nothing
else was eaten, and notes comments

1 - determines client's food intake through questioning, but does not probe for
additional information

0 — obtains sketchy discription about client's food intake

... identifies how much the client eats and drinks

2 - uses food models,hands, etc. to gain description of portion size for at least
% of the food items generated, and notes comments
1 - determines portion size for some of the food items consumed by the client

0 — rarely if ever attempts to assess amount of food and beverages consumed

 

 

105

identifies food preparation methods

determines how food is prepared for k of the food items consumed, and
notes comments

determines food preparation methods for some of the food items consumed
rarely attempts if at all to identify food preparation methods of foods
eaten

classifies food intake data with food frequency, verifying data obtained

uses the food frequency as a crosscheck at least twice, verifies data,
and notes comments

uses the food frequency as a crosscheck at least twice, but does not
verify data and/or note comments

attempts to use food frequency no more than once, or does not verify
or note comments

determines eating behavior by identifying information for the following
variables

investigates topic and notes comments

inquires minimally about topic and notes comments,
investigates topic but fails to note comments, or
notes comments freely elicited about topic.

does not seek information about variable,

inquires minimally but fails to note comments, or

does not acknowledge in notes comments freely elicited.

states questions that relate to the purpose of the diet history

states questions that relate to the purpose of the diet history
more often than not

states questions that are irrelevant to the diet history in several
instances

states at least 5 questions that are totally irrelevant to the
purpose of the diet history.

 

BI BLIOGRAPI—IY

BIBLIOGRAPHY

Accreditation Manual for Hospitals. 1976 edition. Chicago: Joint
Commission on Accreditation of Hospitals, 1976, pp. 65—68.

Adelson, S. F. Some Problems in Collecting Dietary Data from
Individuals. J. Am. Dietet. A. 362453-461, 1960.

Andrews, D. H., and Goodson, L. A. A Comparative Analysis of Models
of Instructional Design. Journal of Instructional Development
3(4): 2-16, 1980.

Bartholomew, M. J., and Poston, F. E. Effect of Food Taboos on
Prenatal Nutrition. J. Nutrn. Ed. 2(1): 15-17, 1970.

Beal, V. A. The Nutritional History in Longitudinal Research.
J. Am. Dietet. A. 51:426-432, 1967.

Beaudoin, R., and Mayer, J. Food Intakes of Obese and Non-Obese Women.
J. Am. Dietet. A. 29:29-33, 1953.

Becker, R. G.; Indik, B. P.; and Beeuwkes, A. M. Dietary Intake
Methodologies--A Review. Tech. Rept. 03188-2T. Ann Arbor:
Univ. Mich. School Pub. Health, 1960.

Bell, C. G. Role vs. Entry-Level Competencies in Competency-Based
Education. J. Am. Dietet. A. 69:133-137, 1976.

Blecha, E. E. Dietary Study Methods. IV. The Dietary History for
Use in Diet Therapy. J. Am. Dietet. A. 27:968-969, 1951.

Bransby, E. R.; Daubney, C. G.; and King, J. Comparison of Results
Obtained by Different Methods of Individual Dietary Survey.
Br. J. Nutrn. 2:89-110, 1947.

Bray, G. A.; Zachary, B.; Dahms, W. T.; Atkinson, R. L.; and Oddie,
T. H. Eating Patterns of Massively Obese Individuals. Direct
vs. Indirect Measurements. J. Am. Dietet. A. 72:24-27, 1978.

Burke, B. S. The Dietary History as a Tool in Research. J. Am.
Dietet. A. 23:1041-1046, 1947.

Chalmers, F. W.; Clayton, M. M.; Gates, L. 0.; Tucker, R. E.; Wertz,

A. W.; Young, C. M.; and Foster, W. D. The Dietary Record--
How Many and Which Days? J. Am. Dietet. A. 28:711-717, 1952.

106

 

 

107

Cochran, S. B., and Spears, M. C. Student Self-Assessment and
Instructors' Ratings: A Comparison. J. Am. Dietet. A.
76:253—257, 1980. '

Cornfield, J., and Tukey, J. W. Values of Mean Squares in Factorials.
Annals of Mathematical Statistics 27:907—949, 1959.

Cross, K. P. Accent on Learning. San Francisco: Jossey—Bass
Publishers, 1976.

Danish, S. J. Developing Helping Relationships in Dietetic Counseling.
J. Am. Dietet. A. 67:107—110, 1975.

Davis, R.; Alexander, L.; and Yelon, S. Learning System Design: An
Approach to the Improvement of Instruction. New York: McGraw—
Hill, Inc., 1974.

Diet Therapy Section Committee. Guidelines for Diet Counseling.
J. Am. Dietet. A. 66:571-575, 1975.

Directory of Dietetic Programs. Chicago: Am. Dietet. Assoc., 1979.

Eads, M. G., and Meredith, A. P. Nutrition Studies. 2. Methods of
Collecting Dietary Data. Pub. Health Rep. 63:777-782, 1948.

Ebel, R. L. Psychometriker, Vol. 16(4):411-4l6, 1951.

Essentials for Coordinated Program in Dietetics with Self Study Guide.
Chicago: Am. Dietet. Assoc., 1976.

Forcier, J. 1.; Right, M. A.; and Sheehan, E. T. Point of View:
Acculturation in Clinical Dietetics. J. Am. Dietet. A. 70:
181-185, 1977.

Freedman, D.; Pisani, R.; and Purves, R. Statistics. New York:
W. W. Norton and Co., Inc., 1978.

Galbraith, A. L. Hospital Dietetics in Transition. J. Am. Dietet. A.
67:439—444, 1975.

General Dietetics Coordinated Study Plan Admissions Committee. Proposed
Eligibility Criteria and Selection Procedures for the GDCSP.
Michigan State University, 1978.

Gersovitz, M.; Madden, J. P.; and Smiciklas-Wright, H. Validity of
the 24-Hour Dietary Recall and Seven-Day Record for Group
Comparisons. J. Am. Dietet. A. 73:48-55, 1978.

Gifft, H. H.; Washbon, M. B.; and Harrison, G. G. Nutrition, Behavior
and Change. Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1972.

 

108

Gines, D. J. Bridging the Gap Between Didactic and Experiential
Learning: Employee Progress Interviews. Unpublished manuscript.
Ph.D. dissertation, Michigan State University, 1978.

Grotkowski, M. L., and Sims, L. S. Nutritional Knowledge, Attitudes
and Dietary Practices of the Elderly. J. Am. Dietet. A. 72:499-
506, 1978.

Harper, P. H.; Goyette, C. H.; and Conners, C. K. Nutrient Intakes of
Children on the Hyperkinesis Diet. J. Am. Dietet. A. 73:515—520,
1978.

Hiob, P. F. A Self-Instructional Manual for the Systematic Development
of Modules. Unpublished manuscript. Ph.D. dissertation,
Michigan State University, 1978.

Hirsch, E. 2.; Benassi, R.; Liddle, L.; and Rogers, P. An Inter-
disciplinary Clinical Training Program for Dietitians.
J. Am. Dietet. A. 70:149¢156, 1977.

Hoban, J. D. Successful Simulations for Health Education, AVI.
23(9):20-24, 1978.

Huenemann, R. L. Interpretation of Nutritional Status. J. Am.
Dietet. A. 63:123-124, 1973.

Huenemann, R. L., and Turner, D. Methods of Dietary Investigation.
J. Am. Dietet. A. 18:562-568, 1942.

Hutter, M. J.; Dungy, C. 1.; Zakus, G. E.; Moore, V. J.; Ott, J.E. ;
and Favret, A. C. Interviewing Skills: A Comprehensive Approach
to Teaching and Evaluation. Journal of Medical Education 52 328-
333, 1977.

Jacobson, H. N. Dietary Practices, Services, and Trends in the Teaching
Hospitals in New Jersey. Nutrn. Today 10(5,6):25-28, 1975.

Johnson, C. A. The Need for Better Nutritional Care-~Who's Responsible?
J. Am. Dietet. A. 67:219-221, 1975.

Koehne, M. The Probable Accuracy of Dietary Studies. J. Am. Dietet. A.
11:105-109, 1935.

Kohrs, M. B.; O'Hanlon, P.; Eklund, D. Title VII--Nutrition Program
for the Elderly. I. Contributions to One Day's Dietary Intake.
J. Am. Dietet. A. 722487-492, 1978.

Leverton, R. M., and Marsh, A. G. Comparison of Food Intakes for
Weekdays and for Saturday and Sunday. J. Home Econ. 31 Ill—114,
1937.

 

109

Lindquist, E. F. Design and Analysis of Experiments in Psychology and
Education. Boston: Houghton-Mifflin, pp. 357-382, 1953.

Lumsden, J. B.; Zolber, K.; Strutz, P.; Moore, S. T.; Sanchez, A. T.;
and Abbey, D. Delegation of Functions by Dietitians to Dietetic
Technicians. J. Am. Dietet. A. 69 143-148, 1976.

Mason, M.; Wenberg, B. G.; and Welsch, P. K. The Dynamics of Clinical
Dietetics. New York: John Wiley and Sons, 1977.

Morrissey, M. J. The Application of the Problem-Oriented Medical
Record to Client Nutritional Care: A Self—Instructional Module
for Dietetic Students. Unpublished manuscript. M.S. Thesis,
Michigan State University, 1976.

Niehoff, A. Changing Food Habits. J. Nutrn. Ed. l(1):lO—11, 1969.

Ohlson, M. A.; Jackson, L.; Boek, J.; Cederquist, D. C.; Brewer, W. D.;
and Brown, E. G. Nutrition and Dietary Habits of Aging Women.
Am. J. Pub. Health 40 1101-1108, 1950.

Reed, R. B., and Burke, B. S. Collection and Analysis of Dietary
Intake Data. Am. J. Pub. Health 44:1015—1026, 1954.

Roth, M. S. Design Your Own Evaluation Tools. AVI. 23(8):21—24, 1978.

Schiller, M. R., and Vivian, V. M. Role of the Clinical Dietitian.
II. Ideal vs. Actual Role. J. Am. Dietet. A. 65:287—290, 1974.

Shapiro, L. R. Streamlining and Implementing Nutritional Assessment:
The Dietary Approach. J. Am. Dietet. A. 75:230-237, 1979.

Short, S. Innovations in Nutrition Education. Audiovisual Instruction
l6(8):l9-21, 1971.

Sims, L. S. Dietary Status of Lactating Women. I. Nutrient Intake
From Food and Food Supplements. J. Am. Dietet. A. 73:139-146,
1978.

Stefanik, P. A., and Trulson, M. F. Determining the Frequency Intakes
of Foods in Large Group Studies. Am. J. Clin. Nutrn. 11:335—343,
1962.

Stevens, H. A., Bleiler, R. E., and Ohlson, M. A. Dietary Intake of
Five Groups of Subjects: 24-Hour Recall Diets vs. Dietary
Patterns. J. Am. Dietet. A. 42:387-393, 1963.

Stillman, P. L.; Ruggill, J. S.; Rutala, P. J.; and Sabers, D. L.
Patient Instructors as Teachers and Evaluators. J. Med. Ed.
55(3):186-193, 1980.

 

 

 

110

Study Commission on Dietetics: The Profession of Dietetics. Chicago:
Am. Dietet. Assoc., 1972.

Tobias, A. L., and Van Itallie, T. B. Nutritional Problems of
Hospitalized Patients. A Preliminary Survey. J. Am. Dietet. A.
71:253-257, 1977.

Tower, J. B., and Vosburgh, P. M. Development of a Rating Scale to
Measure Learning in Clinical Dietetics. I. Theoretical Con—
siderations and Method of Construction. J. Am. Dietet. A.
68:440—445, 1976.

Trulson, M. F. Assessment of Dietary Study Methods. I. Comparison
of Methods for Obtaining Data for Clinical Work. J. Am. Dietet.
A. 30:991-995, 1954.

Trulson, M. F. Assessment of Dietary Study Methods. II. Variability
of Eating Practices and Determination of Sample Size and Duration
of Dietary Surveys. J. Am. Dietet. A. 31:797-802, 1955.

Trulson, M. F., and McCann, M. B. Comparison of Dietary Survey Methods.
J. Am. Dietet. A. 35:672-676, 1959.

Turner, D. The Estimation of the Patient's Home Dietary Intake.
J. Am. Dietet. A. 16:875-881, 1940.

Unklesbay, N., and Spears, M. C. Attachment Learning: A Humanistic
Educational Experience. J. Am. Dietet. A. 67:449-454, 1975.

van den Berg, A. S., and Mayer, J. Comparison of One-Day Food Record
and Research Dietary History on a Group of Obese Pregnant Women.
J. Am. Dietet. A. 30:1239-1244, 1954.

Weed, J. B., and Molleson, A. L. Establishing Guidelines for Peer
Review of the Clinical Dietitian. J. Am. Dietet. A. 70:157—160,
1977.

Wilson, N., and Wilson, R. H. L. You Can Lead a Patient to a Diet,
But . . . . Nutrn. Today l(l):l4-I8, 1966.

Young, C. M. Interviewing the Patient. Am. J. Clin. Nutr. 8:523—526,
1960.

Young, C. M. The Therapeutic Dietitian-—A Challenge for Cooperation.
J. Am. Dietet. A. 47:96-103, 1965.

Young, C. M.; Chalmers, F. W.; Church, H. N.; Clayton, M. M.; Tucker,
R. B.; Werts, A. W.; and Foster, W. D. A Comparison of Dietary
Study Methods. 1. Dietary History vs. Seven-Day Record. J. Am.
Dietet. A. 28:124—128, 1952.

111

Young, C. M.; Hagen, G. C.; Tucker, R. E.; and Foster, W. D. A
Comparison of Dietary Study Methods. II. Dietary History
vs. Seven-Day Record vs. 24-Hour Recall. J. Am. Dietet. A.
28:218-221, 1952.

Young, C. M., and Trulson, M. F. Methodology for Dietary Studies in
Epidemiologic Surveys. II. Strengths and Weaknesses of Existing
Methods. Am. J. Pub. Health 50:803-814, 1960.

 

IIIIIIIIIIIIIIIIIIII3IIIIIIIIIIIIIIIIIIIIIIQIIIIIIII7IIIIIIIII2IIIII